Every fall, Kentuckians are flooded with advertisements for Medicare Advantage plans promising attractive benefits, from grocery allowances and gym memberships to dental and vision coverage. For older adults living on fixed incomes, those extras can make a real difference. But when choosing health coverage, the benefits that catch your attention are not always the ones that matter most when you need medical care.
Will your trusted doctor still be in your network? Will your local hospital accept your plan? And if you need rehabilitation after surgery or a serious illness, will your insurance cover the care your physician recommends?
These are questions that patients and families across Kentucky face every day. At the Kentucky Hospital Association, we know how important it is for patients to have access to the right care at the right time, particularly in rural communities where health care options may already be limited. As Medicare’s annual open enrollment period approaches, I encourage Kentuckians to look beyond the extras and ask a more important question: Will my health plan be there when I need it most?
A recent federal investigation offers an important reminder of why these questions matter. In June, the U.S. Department of Health and Human Services Office of Inspector General released findings showing that Medicare Advantage insurers denied 12% of requests for skilled nursing facility admission in a sample of requests from June 2024. Of those denials, just 18% were appealed. But when patients and providers did appeal, insurers overturned 95% of the denials, raising concerns about patients who may have been initially denied medically necessary care.
Consider what that means for someone recovering from a stroke, a broken hip, or major surgery. Leaving the hospital is not always the end of treatment. Many patients need rehabilitation or skilled nursing care before they can safely return home. When that care is delayed or denied, patients and their families face additional uncertainty during an already difficult time. For Kentucky hospitals, helping patients transition safely to the next level of care is an important part of the work we do every day. That is why understanding your coverage before you need it is so important.
One of the most important questions to ask is whether your doctors, specialists, and local hospital participate in the plan you are considering. Medicare Advantage plans have different network requirements, and those networks can vary significantly from one plan to another. A hospital that accepts one Medicare Advantage plan may not participate in another. The same is true for physicians, rehabilitation facilities, and home health providers.
In rural Kentucky, where access to health care may already require a long drive, a limited network can create additional challenges. Before choosing a plan, contact your trusted providers and confirm they participate in that specific plan for the coming year. If you regularly see a specialist, ask whether you will need a referral and whether that physician remains in your network. And do not forget to ask about the rehabilitation facilities and other providers you might need after a hospital stay.
It is equally important to understand what happens when your doctor recommends care. Many Medicare Advantage plans require prior authorization before certain treatments, procedures, or services are covered. While prior authorization is intended to help ensure care is appropriate, the approval process can sometimes create delays or additional challenges for patients. Ask which services require approval, how those decisions are made, and what happens if a request is denied. Understanding the process now can help you navigate it if your health needs change unexpectedly.
Medicare’s annual open enrollment period runs from October 15 through December 7. This is an opportunity to review your current coverage, compare your options, and make sure your plan still meets your needs. Look at the complete picture, including premiums, out-of-pocket costs, prescription drug coverage, provider networks, and any changes to your benefits for the coming year. Kentuckians who need help comparing their options can also contact the Kentucky State Health Insurance Assistance Program, which provides free, unbiased Medicare counseling.
Medicare Advantage may be the right choice for some Kentuckians. Others may find that Original Medicare better meets their needs. There is no single answer for everyone. What matters is making a decision based on your health, your circumstances, and the care you may need in the year ahead.
The extras can be appealing. But when your health is on the line, access to trusted doctors, local hospitals, and the care you need matters most.
This open enrollment season, look beyond the extras. Choose care, not just perks.
Melanie Landrum is the Interim CEO of the Kentucky Hospital Association.