By Fred Riccardi, Medicare Rights Center President and Next Avenue Contributor
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Beginning this year and continuing into 2020, Medicare Advantage plans (ones from private insurers) have increased flexibility to provide coverage for what the government calls supplemental benefits. These are services otherwise excluded by law from what’s known as Original Medicare coverage.
And Medicare Advantage plans for 2020 can begin covering supplemental benefits that aren’t primarily health-related, specifically for people with chronic illnesses. These benefits address environmental factors that may affect their health, functioning, quality of life and risk levels. So you may be seeing plans offering people with chronic ailments coverage for things like meal delivery, transportation for non-medical needs, home air cleaners, and heart-healthy food.
Now that it’s the heart of Medicare Open Enrollment season, ending Dec. 7, if you or a loved one will be shopping for Medicare coverage for 2020, you’ll want to know about these new supplemental benefits and how to size them up before choosing a plan.
Criteria for a Chronic Condition for Medicare Supplemental Benefits
Having a chronic condition, according to Medicare rules, means that you meet these three criteria:
- You have at least one medically complex chronic condition that is life-threatening or significantly limits your health or function
- You have a high risk of hospitalization or other negative health outcomes
- You require intensive health care coordination
If you meet these criteria, a Medicare Advantage plan may offer you one of the new benefits if the service or product has a reasonable expectation of improving or maintaining your health or function.
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Since Medicare Advantage plans will be able to create sets of supplemental benefits for people with specific chronic illnesses, not every member of a particular plan will have access to the same set of benefits. For example, a plan might cover services like home air cleaning and carpet shampooing for members with severe asthma. So, someone signing up for the plan who has severe asthma may be able to get that service covered, while someone else who doesn’t have asthma, or whose asthma is mild, may not.
Before enrolling in a Medicare Advantage plan with new supplemental benefits for people with chronic conditions, contact the insurer to learn if you’d be eligible for them, and if so, how to access the coverage.
You can also read a plan’s Evidence of Coverage or use the government’s Medicare Plan Finder for 2020. And for help understanding a plan’s benefits, contact your State Health Assistance Program by calling 877-839-2675 or visiting the website for these programs.
Questions to Ask When Buying a Medicare Advantage Plan
If you’re thinking of enrolling in a Medicare Advantage plan with supplemental benefits, consider the following questions:
- Is this service only covered as a Medicare Advantage supplemental benefit or is it also covered under Original Medicare? To find out, call Medicare (800-MEDICARE) or visit the government’s Medicare site.
- If I sign up for a Medicare Advantage plan because it contains this benefit, will my health care providers be in-network and will my prescription drugs be covered?
- Is this benefit offered to all enrollees in this Medicare Advantage plan; an optional benefit I need to elect to receive or something just for plan members with chronic conditions?
- Do I meet the plan’s coverage criteria to receive the supplemental benefit?
- Is there a cost associated with this benefit?
- Are there any limits or restrictions on covered supplemental benefits? For example, is there a set number of rides for a transportation benefit or a dollar limit on eyeglasses?
- Do I need to see in-network providers, receive a referral or participate in a care management program to be eligible for the benefit?
- Are there excluded services within this category of benefits?
- Is this the most cost-effective way for me to access these services?
In some cases, there may be no Medicare Advantage plan in your area with supplemental benefits you could use. Or you might find that Original Medicare offers better coverage of services that are important to you. If so, you may still be able to receive some services that Original Medicare does not cover. Here’s how:
Medigap plans: Generally, these plans, also known as Medicare supplemental insurance, only pay secondary to Medicare when Medicare covers a service. However, some also cover additional days of inpatient hospital care and/or emergency medical services received outside of the United States which aren’t covered by Original Medicare. Some Medigap plans also offer fitness benefits or other targeted supplemental coverage in some states.
Medicaid: This is a federal and state program that provides health coverage for certain people with limited income and assets. In some states, Medicaid covers services that Medicare doesn’t, including dental, vision, long-term care and transportation for health care. To learn more about your state’s Medicaid program, contact your State Health Assistance Program.
Reduced-cost or free clinics: For more information about these, check out the resources at these sites: Needymeds.org, Healthcare.gov, Freeclinics.com and the Health & Human Services department’s site, HHS.gov.
Donated dental service programs or dental schools: Dentists in the programs offer free dental services if you qualify. You may also be able to get low-cost dental care at a dental school, where dental students work with patients under the supervision of experienced, licensed dentists.
For more information about Medicare options, you can visit Medicare Interactive, the Medicare Rights Center’s free online resource.