Most MA plans are HMOs, with a network of practitioners. If you wish to see someone outside the network, or in a state or city where the network has no practitioners, you’re out of luck. (Some MA policies are PPOs and will partially cover out-of-network practitioners, usually at a cost.)
MA policies must cover emergency care in out-of-state, non-network facilities, but “emergency” is narrowly defined. For example, if you break a wrist, hip, or ankle while out of state, the initial emergency room response will be covered (minus co-pays and co-insurance). But for follow-up care to be covered, you’ll have to return to your home city and see a network practitioner.
More importantly, MA plans recoup their costs through a schedule of co-pays and co-insurances. These can add up quickly. Co-pays for hospital stays will usually be over $250 per day for the first five to seven days of each hospitalization. That’s in addition to co-pays for ambulance services, the emergency room doctor, other doctors, medical equipment, diagnostic tests, and on and on. A few days in the hospital may cost as much as a year of Medigap premiums. (Of course, you may go many years without needing hospitalization and incurring these costs.)
An ad I received recently for a MA policy touted a long list of zeros: zero premium, zero co-pay for regular medical appointments, zero co-pay for lab work, and finally, zero co-pay for “hospital stays (days 7-90).” It didn’t mention that days 1-6 would cost $265 per day out-of-pocket.
Trying to compare MA policies is an exercise in frustration. In my county, there are fourteen HMO MA plans. Each has a different schedule of hospital co-pays that differ both in the amount charged and the number of days a co-pay is required. One plan charges $175 per day for the first seven days of hospitalization. A three-day hospital stay would cost $525 while a seven-day stay would be $1050. Another plan charges $350 per day for the first three days. Both a three day and seven day stay would cost $1050. (And so on through fourteen sets of possibilities.)
And that’s just hospital co-pays. Ambulance co-pays for the 14 plans go from a low of $100 to a high of $400. Co-pays for specialist visits and rehab service differ as well. Your yearly cost is unpredictable, depending on what services you use. A policy that’s a good deal given one set of circumstances may be a poor choice for a different set of circumstances. Unless you can correctly predict what services you’ll need in a given year, selecting an MA policy is a shot in the dark.
You can change plans during Open Enrollment every year, but few people do, since their doctors and care team are associated with their plan.