Social Security & Medicare Questions: March 2011

Social Security & Medicare Questions: March 2011

Q: I’ve learned I’ll need to be hospitalized for surgery. My health benefits are through a Medicare Advantage Plan. Can you tell me what to expect in the way of out-of-pocket costs?

A: Medicare Advantage plans provide all your Part A (hospital insurance) and Part B (doctors and hospital outpatient) benefits, but you need to thoroughly understand how your plan works to get the maximum out of your coverage. Unlike the coverage under Medicare using a Medigap plan, Medicare Advantage plans can charge different deductibles and co-pays, and the plans have different rules for how you get services. Here are some important points:

• Check with your health plan BEFORE you’re hospitalized to find out whether they will cover the service. Your plan’s customer service department may be able to give you an estimate of what your costs may be.

• You must follow plan rules. For example, you may need to get a referral to a specialist from your primary care physician to avoid higher costs or loss of coverage. Check with your plan.

• If you go to a hospital or your doctor doesn’t belong to your health plan network, your services may not be covered, or your costs may be higher because they are “out-of-network.” Find out if your doctor and hospital are in the plan network and whether they are “preferred providers.”

Unlike Medigap plans which cover most or even all of the out-of-pocket costs of hospitalization, Medicare Advantage plans may charge you any or all of the following, depending on your health plan and the services you receive:

• A deductible.
• Copays that can cost more than $225 per day for the first 1 to 7 days of inpatient care.
• Copays for days 8-90 of inpatient care.
• A coverage limit to the number of days covered in the benefit period.
• Copays for each service you receive from doctors, surgeons, anesthesiologists, therapists, etc.
• Copays for anesthesia, drugs, and any supplies you receive.
• Copays for covered tests, X-rays, imaging and lab work.

One new change under healthcare reform limits the out-of-pocket costs that Medicare Advantage plan can charge in 2011 to $6,700, although approximately 50 percent of plans have lower limits.

To learn more about Medicare Advantage and how it works, check your copy of “Medicare & You 2011” that you received in the fall of 2010, visit or call 1-800-MEDICARE (1-800-633-4227).