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Health Line
02-07-2025
- Health
- Health Line
What Are Some Drawbacks of Medicare Advantage for Doctors?
Although Medicare Advantage plans offer beneficiaries a variety of attractive features, there are some aspects of these private plans that healthcare professionals may dislike. Medicare Advantage (Part C) plans offer eligible individuals an alternative to Original Medicare (parts A and B). These plans, which are offered by Medicare-approved private insurance companies, combine the hospital and medical insurance of Original Medicare with various other benefits, like dental, vision, and hearing care. Medicare Advantage overview People who join Medicare Advantage plans may do so for reasons including: Customization: There are many plan options from numerous insurers, allowing you to find a plan that meets your specific healthcare needs. Convenience: These plans allow you to bundle all your health insurance coverage under a single plan. Affordability: Medicare Advantage plans often have low (or no) monthly premiums, out-of-pocket maximums, and low deductibles. While enrollees value these benefits, doctors may find some of the administrative hurdles associated with these plans to be challenging. Potential issues with Medicare Advantage plans include: requiring prior authorization for procedures that Original Medicare does not denying coverage for certain services limiting members to strict provider networks Prior authorization requirements Medicare Advantage plans commonly require beneficiaries to get prior authorization before receiving services or equipment. Original Medicare, on the other hand, generally does not require prior authorization. The health policy research nonprofit KFF reports that 99% of people enrolled in Medicare Advantage plans in 2023 required prior authorization for some services. While these requirements can help prevent wasteful procedures and allow insurers to keep costs low, they can also lead to delays in care and administrative headaches for healthcare professionals. A 2024 survey from the American Medical Association found that doctors and their staff spend 13 hours per week on average completing prior authorization requests. And a 2023 article notes that these administrative burdens can be a source of 'frustration and clinician burnout' for staff. Denials of service One possible outcome of the process of requesting prior authorization is that you receive a denial of service. In cases where a healthcare professional considers a procedure medically necessary, this can lead to a potentially drawn-out appeals process that increases a physician's workload. Further, it has the potential to negatively affect patient care and disrupt treatment. KFF reports that in 2023, 3.2 million prior authorization requests were fully or partially denied. This represents about 6.4% of all requests. Of the denials that were appealed, 81.7% were overturned. Network restrictions Medicare Advantage plans impose strict network restrictions on their members. These restrictions may create issues when doctors are making specialist referrals or sending patients to other facilities for care. Some people enrolled in Medicare Advantage plans report having trouble finding the necessary care within their plan's network. This can be a particular issue for people living in rural areas where provider access is already limited. Other issues Complexity is another factor that some healthcare professionals may face with Medicare Advantage plans. There are many plans from many carriers, and these plans can have a range of different coverage rules. Managing this complexity on a case-by-case basis can take a lot of time, adding to the administrative burden discussed above. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Health Line
30-06-2025
- Health
- Health Line
What is a Medicare advisor?
A Medicare advisor is a licensed professional who can help you evaluate and select the right Medicare plan for your budget and needs. The two main types of Medicare advisors are independent insurance agents and brokers. Navigating Medicare can be confusing. However, Medicare advisors can help you understand the different parts, costs, and coverage. It is important to check their licensing before choosing which one to use. Types of Medicare advisors There are different types of Medicare advisors — the two main types are brokers and agents. Medicare brokers A Medicare broker is a licensed individual who represents multiple insurance companies. They can help you evaluate plan options. As Medicare brokers are not tied to a particular insurance company, they can help walk you through various plans from different companies to find the best one for your coverage needs and budget. Once they help you choose a plan, they will then connect you with an agent from the insurance company to help you with the enrollment process. A Medicare broker may be the best option if you are unfamiliar with the insurance companies that offer Medicare Advantage (Part C), Part D, or Medigap plans and want to compare a variety of plans. Medicare agents Medicare agents are licensed individuals who help enroll people in various insurance products, such as Medicare Advantage, Part D, and Medigap. There are two types of Medicare agents: Independent: An independent agent is a contractor who represents different insurance companies. They search for the best plans based on each client's individual needs. Captive: A captive agent is an individual who represents an individual insurance company and is required to sell only plans from that company. Federal requirements for Medicare agents hold a license in the states where they do business use approved marketing materials test and train annually on their knowledge of Medicare health and prescription drug plans agree to the scope of appointment via document or phone call before meeting with potential enrollees SHIP volunteers The State Health Insurance Assistance Program (SHIP) is a federally funded state-based organization that provides Medicare counseling and information to beneficiaries and their caregivers. SHIP counselors are all volunteers. They offer unbiased one-to-one counseling and assistance. SHIP also screens, trains, and certifies all its volunteers as Medicare experts. To contact SHIP, you can call 877-839-2675 or find your local SHIP office. Contacting Medicare You can contact Medicare directly with any questions you may have. The Medicare line is open 24/7, except for certain federal holidays. How do Medicare advisors get paid? It is rare for a beneficiary to pay a Medicare advisor anything out of pocket. Generally, Medicare advisors are paid via commission for enrollment and retention in Medicare Advantage, Part D, and Medigap plans. They may also be offered further compensation for: administrative payments for marketing bonuses for meeting enrollment benchmarks selling other health-related insurance products, such as hospital indemnity insurance other activities for plans, such as beneficiary health risk assessments The Centers for Medicare & Medicaid Services (CMS) requires that agent compensation for Medicare Advantage and Medicare Part D plans be at or below fair market value. The following table gives examples of compensation for 2025. Compensation type National maximum Medicare Advantage initial year $626 Medicare Advantage renewal year $313 Medicare Part D initial year $109 Medicare Part D renewal year $55 For each Medicare Advantage or Plan D plan renewal or switch to a new similar plan, the Medicare advisor is paid up to 50% of the fair market value. For Medigap plans, agents are given about 20% initial enrollment and 10% for each subsequent year. What to look for when choosing a Medicare advisor When choosing a Medicare advisor, there are certain criteria you may want to consider: Licenses: Be sure to check that your chosen advisor is licensed by your state insurance department, as required by CMS. Also, check to be sure they are a member of the AHIP, the national trade association for the health insurance industry. Scope of services: Consider the services an advisor offers. If you are unfamiliar with the top companies that provide Medicare plans, a Medicare broker may be a better option. If you would rather work with only one intermediary, an agent may be more suitable. Support offered: Consider whether the Medicare advisor will provide support if you have questions or run into problems after you purchase a plan. Summary Medicare advisors are licensed individuals who can help you choose and enroll in a Medicare plan. There are two main types of Medicare Advisors — brokers and agents. Each one of these can help you in different ways. You can also contact the State Health Insurance Assistance Program (SHIP) and get unbiased one-to-one counseling on Medicare issues and questions. Medicare also has a helpline that you can call or chat online with 24/7. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Health Line
16-06-2025
- Health
- Health Line
Choosing a Medicare Advantage Plan That's Right for You
There are many factors to consider when choosing a Medicare Advantage (Part C) plan, including costs, in-network providers, and coverage for medical services and prescription medications. If you're shopping for a Medicare Advantage (Part C) plan this year, you may wonder what the best plan is for you. It depends on your personal situation, medical needs, how much you can afford, and other factors. Tools are available to help you find Medicare Advantage plans in your area that can meet all your healthcare needs. Glossary of common Medicare terms Out-of-pocket cost: This is the amount you pay for care when Medicare doesn't pay the full cost or offer coverage. It includes premiums, deductibles, coinsurance, and copayments. Premium: This is the monthly amount you pay for Medicare coverage. Deductible: This is the annual amount you must spend out of pocket before Medicare begins to cover services and treatments. Coinsurance: This is the percentage of treatment costs you're responsible for paying out of pocket. With Medicare Part B, you typically pay 20%. Copayment: This is a fixed dollar amount you pay when receiving certain treatments or services. With Medicare, this often applies to prescription medications. Factors to consider when choosing a Medicare Advantage plan With all the changes being made to the Medicare plans on the market, it can be hard to narrow down the best plan for you. Here are a few things to look for in a Medicare Advantage plan: costs that fit your budget and needs a list of in-network providers that includes any doctor(s) you would like to keep coverage for services and medications you know you'll need Centers for Medicare & Medicaid Services (CMS) star rating Research CMS star ratings The CMS has implemented a 5-star rating system to measure the quality of health and drug services provided by Medicare Advantage and Medicare Part D (prescription drug) plans. Every year, the CMS releases these star ratings and additional data to the public. The CMS ratings can be a great place to start when shopping around for the best Medicare Advantage plan in your state. Consider researching these plans for more information on what coverage is included and how much it costs. To see all available Medicare Part C and D 2025 star ratings, visit and download the 2025 Medicare Star Ratings Data Table. Consider your coverage priorities All Medicare Advantage plans cover what Original Medicare covers — this includes hospital coverage (Part A) and medical coverage (Part B). When you choose a Medicare Advantage plan, you first want to consider what type of coverage you need in addition to the coverage above. Most Medicare Advantage plans offer one, if not all, of these additional types of coverage: prescription drug coverage dental coverage, including yearly exams and procedures vision coverage, including yearly exams and vision devices hearing coverage, including exams and hearing devices fitness memberships medical transportation additional healthcare perks Finding the best Medicare Advantage plan means making a checklist of the services you want to receive coverage for. You can then take your coverage checklist to Medicare's find a plan tool and compare plans that cover what you need. If you find a plan that looks good for you, don't be afraid to call the company to ask if they offer any additional coverage or perks. Determine your budget and potential healthcare costs One of the most important things to consider when choosing the best Medicare Advantage plan is how much it will cost you. The find a plan tool lists the following cost information with the plans: monthly premium Part B premium in-network yearly deductible drug deductible in- and out-of-network out-of-pocket max copays and coinsurance To get a starting estimate of your yearly costs, consider the premium, deductible, and out-of-pocket max. Any deductible listed is the amount you'll owe out of pocket before your insurance begins to pay out. Any out-of-pocket max listed is the maximum amount you will pay for the services throughout the year. When estimating your plan costs, consider these costs plus how often you will need to refill prescription drugs or make office visits. If you require specialist or out-of-network visits, include those potential costs in your estimate as well. Remember that your amount may be lower if you receive financial assistance from the state. Review other benefits you may already have If you already receive other types of healthcare benefits, this may factor into what kind of Medicare Advantage plan you'll need. For example, if you already receive Original Medicare and have opted to add Part D or Medigap, many of your needs may already be covered. However, you can always do a coverage comparison to determine whether a Medicare Advantage plan would work better or be more cost-effective for you. What Medicare Advantage plans are available? When beginning your search for a Medicare Advantage (Part C) plan, it's important to know the differences between each type of plan. You'll probably see some or all of the following types of plans when reviewing your options: Health Maintenance Organization (HMO) plans: HMO plans are primarily focused on in-network healthcare services. Preferred Provider Organization (PPO) plans: PPO plans charge different rates depending on whether the services are in or out of network. (A 'network' is a group of providers who contract to provide services for the specific insurance company and plan.) PPO plans may provide more options to receive out-of-network care. Private Fee-for-Service (PFFS) plans: PFFS plans let you receive care from any Medicare-approved provider who will accept the approved fee from your plan. Special Needs Plans (SNPs): SNPs offer additional help for medical costs associated with specific chronic health conditions. Medicare Savings Account (MSA) plans: MSA plans combine a high-deductible health plan with a medical savings account. Each plan offers options to accommodate your healthcare needs. For example, if you have chronic health conditions, SNPs are designed to help alleviate some long-term costs. On the other hand, a PFFS or MSA plan might be beneficial if you travel and need to see out-of-network healthcare professionals. When do you sign up for a Medicare Advantage plan? The Medicare enrollment process can begin as early as 3 months before you or your loved one turns 65 years old. This is the best time to apply, as it will ensure that you receive coverage by your 65th birthday. You can wait to apply for Medicare until the month of your 65th birthday or the 3 months following your birthday. However, coverage can be delayed if you wait, so try to apply early. If you decide not to enroll in a Medicare Advantage plan when you first turn age 65, you have another chance during Medicare's annual open enrollment period. From October 15 through December 7 each year, you can switch from Original Medicare to Medicare Advantage. You can also switch from one Medicare Advantage plan to another or add, remove, or change a Part D plan. The takeaway There are many factors that can influence which Medicare Advantage plan you choose. Consider the CMS star rating, your priorities and healthcare needs, how much you can afford, and what type of insurance you currently have. It's important to enroll in Medicare before you turn age 65 to ensure that you don't go without medical coverage. Don't forget that you have the power to shop around for the best Medicare Advantage plan that fits all your needs. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Health Line
05-06-2025
- Business
- Health Line
Does Medicare Cover Blood Tests for Cholesterol and How Often?
Key takeaways Medicare covers cholesterol testing as part of cardiovascular screening blood tests, including tests for lipid and triglyceride levels, which are covered once every 5 years. For those diagnosed with high cholesterol, Medicare Part B covers continuing blood work to monitor the condition and response to prescribed medication. Cholesterol-lowering medication is typically covered by Medicare Part D (prescription drug coverage) and Medicare Advantage (Part C) plans. Medicare covers cholesterol testing as part of the cardiovascular screening blood tests. It also includes tests for lipid and triglyceride levels, which are covered once every 5 years. However, if you have a diagnosis of high cholesterol, Medicare Part B will usually cover continuing blood work to monitor your condition and response to prescribed medication. If you need cholesterol-lowering medication, it's usually covered by Medicare Part D (prescription drug coverage) and Medicare Part C (Medicare Advantage) plans. Keep reading to learn more about what Medicare covers to help diagnose and prevent cardiovascular disease. What else does Medicare cover to help diagnose and prevent cardiovascular disease? Cholesterol testing isn't the only thing Medicare covers to help identify, prevent, and treat cardiovascular disease. Medicare Part B will also cover an annual visit with your primary care doctor for behavioral therapy, which may include suggestions for a heart-healthy diet. Additional preventive services covered by Medicare Medicare covers other prevention and early detection services — many at no charge — to help identify health issues early. Diagnosing health conditions early can maximize the success of treatment. These tests include: Preventive services Coverage abdominal aortic aneurysm screening 1 screening for people with risk factors alcohol misuse screening and counseling 1 screen and 4 brief counseling sessions per year bone mass measurement 1 every 2 years for people with risk factors colorectal cancer screenings how often is determined by the test and your risk factors depression screening 1 per year diabetes screening 1 for those at high risk; based on test results, up to 2 per year diabetes self-management training if you have diabetes and a written doctor's order flu shots 1 per flu season glaucoma tests 1 per year for people with risk factors hepatitis B shots series of shots for people at medium or high risk hepatitis B virus infection screening for high risk, 1 per year for continued high risk; for pregnant women, 1st prenatal visit and at time of delivery hepatitis C screening for those born 1945 to 1965; 1 per year for high risk HIV screening for certain age and risk groups, 1 per year; 3 during pregnancy lung cancer screening test 1 per year for qualified patients mammogram screening (breast cancer screening) 1 for women ages 35 to 49 years; 1 per year for women ages 40 years and older medical nutrition therapy services for qualified patients (diabetes, kidney disease, kidney transplant) Medicare diabetes prevention program for qualified patients obesity screening and counseling for qualified patients (BMI of 30 or more) Pap test and pelvic exam (also includes a breast exam) 1 every 2 years; 1 per year for those at high risk prostate cancer screenings 1 per year for men over age 50 years pneumococcal (pneumonia) vaccine covered; specific vaccine as recommended by your doctor tobacco use counseling and tobacco-caused disease 8 per year for tobacco users wellness visit 1 per year If you register at you can get direct access to your preventive health information. This includes a 2-year calendar of the Medicare-covered tests and screenings you're eligible for. What to expect from cholesterol testing The cholesterol test is used to estimate your risk of heart disease and blood vessel disease. The test will help your doctor evaluate your total cholesterol and your: Low-density lipoprotein (LDL) cholesterol: Also known as 'bad' cholesterol, LDL in high quantities can cause the buildup of plaques (fatty deposits) in your arteries. These deposits can reduce blood flow and can sometimes rupture, leading to a heart attack or stroke. High-density lipoprotein (HDL) cholesterol: Also known as 'good' cholesterol, HDL helps carry away LDL cholesterol and other 'bad' lipids to be flushed from the body. Triglycerides: Triglycerides are a type of fat in your blood that is stored in fat cells. At high enough levels, triglycerides may increase the risk of heart disease or diabetes. Lipoprotein(a): Your doctor may order this test to check your Lp(a), a type of LDL (bad) cholesterol. Medicare doesn't cover this test. Takeaway Medicare covers the costs of testing your cholesterol, lipid, and triglyceride levels every 5 years. These tests can help determine your risk level for cardiovascular disease, stroke, or heart attack. Medicare also covers other preventive services, including wellness visits, mammogram screenings, colorectal cancer screenings, flu shots, and more. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Medical News Today
02-06-2025
- Business
- Medical News Today
Omeprazole and Medicare coverage
Many Medicare Part D or Part C plans with drug coverage cover omeprazole when a doctor prescribes it. Some Part C plans may even allow a person to buy it over the counter. Omeprazole can be purchased over the counter or with a prescription. However, over-the-counter (OTC) purchases typically cannot be made through a health insurance plan. This article explores how people can use their Medicare Part D prescription plan or Medicare Advantage (Part C) plan with drug coverage to purchase prescription omeprazole and the potential out-of-pocket expenses individuals might encounter. Is omeprazole covered by Medicare Part B? However, Part B only covers medications a person cannot take themselves, such as IV drugs . For this reason, omeprazole coverage falls under Part D. Studies indicate that many Part D plans cover this medication in its prescribed form. In addition, some Part D plans may cover OTC omeprazole if a person has a doctor's prescription. What tier level is omeprazole? Whether a person's specific plan covers the generic omeprazole or Prilosec brand depends on its inclusion in the plan's specific formulary. Within this formulary, every Part D plan categorizes drugs into tiers. Generally, the higher the tier, the more a person will pay out of pocket even after Part D coverage kicks in. While each Part D plan may place omeprazole in a different tier, more commonly prescribed or preferred drugs tend to feature in lower tiers. In addition, formularies are more likely to rank generic omeprazole lower than Prilosec. However, it is essential to understand that certain Part D plans may require individuals to try the OTC version of a medication before approving coverage for the prescription form. This process is known as step therapy. Medicare Advantage However, what is different about such Part C plans is that some may provide an additional benefit for OTC medications, allowing a person to buy the drug over the counter using their plan. How much does omeprazole cost with Medicare? The cost for thirty 40-milligram capsules of generic omeprazole fluctuates between $10 and $48, depending on the pharmacy dispensing it. In contrast, the brand-name drug Prilosec, when a person acquires it under prescription, costs between $448 and $476, making it considerably more expensive than its OTC or generic alternatives. The amount someone pays for prescription Prilosec or non-OTC generic versions after Medicare coverage takes effect depends on the drug's tier classification in their plan's formulary. Drugs in higher tiers typically incur higher costs. Furthermore, Medicare Part C and D plans generally require meeting a deductible and paying a monthly premium, which varies by plan. In 2025, the national base beneficiary premium for Part D is $36.78, while the average monthly premium for Part C is around $17. In addition, a person must still pay the Part B premium to enroll in a Part C plan. However, some plans may cover this cost. What is the best alternative to omeprazole under Medicare? Omeprazole falls into the drug category of proton pump inhibitors (PPIs) and is among the top ten prescribed medications in the United States. That said, there are other PPIs, including: Which of these drugs works best depends on the person, their specific health needs, and the doctor's recommendations. It is also essential to know that not every PPI has approval for treating the same medical conditions. Medicare may not approve coverage if a doctor prescribes a drug off-label or for a reason the insurance does not consider medically necessary.
