It was not so long ago that signing up for Medicare was simple because there were limited choices. Now the choices, in the name of expanding the free market and competition, threaten to overwhelm the beneficiaries.

In the beginning there was Medicare A and B. Part A, premium free for most people, pays for inpatient hospital services. Medicare B, with a monthly premium, pays for physician and outpatient hospital services. Most people sign up for both.

Then came Medicare supplements or Medigap, and you could choose among private policies which would help you cover the gaps in Medicare A and B. Then came Medicare C, currently called Medicare Advantage, where you can buy a private health plan, approved by Medicare, which may offer extra benefits and sometimes charge an extra premium on top of the permanently required Medicare B premium. Medicare D is the latest set of choices - private plans which offer prescription drug coverage.

This is the time of year (January 1 through March 31) when you can enroll in Medicare Advantage plans. Medicare Advantage participation is very low in Vermont; only 1.2 per cent of Medicare beneficiaries have signed up, according to the Kaiser Family Foundation. This compares to 18.5 per cent enrollment in throughout the United States.

"It is very time-consuming to make a choice among the Medicare Advantage plans," says Gail Ireland, coordinator of the State Health Insurance Assistance Program. The plans are not standardized. You must be very clear about your personal needs, the benefits in each plan, and how these benefits compare to original Medicare."

In Chittenden County, you have a choice among 25 Medicare Advantage plans - 24 of which are Private-Fee-for Service; one is a Medical Savings Account. In PFFS plans, Medicare pays a set amount of money each month to the private insurance company to provide health care coverage on a fee-for-service arrangement. The insurance company, rather than Medicare, decides how much you pay for the services you get.

What is the advantage of Medicare Advantage? First, you no longer need a Medigap policy. Compared to Medigap insurance, MA premiums on average are less expensive, ranging from $0 to $151 per month. MA plans cover all medically necessary services covered by Medicare A and B, and some include extra benefits like dental, hearing, vision, or drug coverage. If you choose an MA plan with drug coverage, you can deal with only one company for your health insurance, instead of three with original Medicare, Medigap, and Part D. If you have original Medicare with no supplemental coverage, your out-of-pocket costs may be higher than with some MA plans, which may have low or no co-pays for primary physicians or specialists. But premiums for these low co-pay plans may be higher than in other MA plans. 

What are the downsides to Medicare Advantage? These depend on your health needs, income, and comfort with risk. If vision services are important to you, note that twenty-one of the MA plans offered in Chittenden County cover them; but some plans may not offer much more than original Medicare does. This year in Vermont, PFFS plans allow you to see any doctor that accepts Medicare patients AND who will accept the PFFS plan's terms of payment. But doctors can decide at each visit whether or not to accept your PFFS plan.

Also, PFFS  out-of-pocket costs can be less predictable than those of original Medicare supplemented with Medigap. Ireland points out that in most PFFS plans, you pay a set co-pay for primary care doctors and another, usually higher co-pay for specialists. For other types of covered services, like durable medical equipment, diagnostic tests, chemotherapy, etc., you may pay a percentage of the cost, which can be quite high and hard to predict. In some plans, your cost sharing may be higher than in original Medicare. For example, in original Medicare, the deductible for hospitalization is $1024 per benefit period; but one PFFS plan has a $100 daily co-pay for the first 29 days of hospitalization.

"If your health is good, you might save with a low premium MA plan," says Ireland. "If your health is poor, you could pay more than with traditional Medicare."

Finally the MA plans are built on controversial federal subsidies. PFFS plans are paid, on average, 19 per cent more per beneficiary than the cost of traditional Medicare, a subsidy that costs each general Medicare beneficiary two dollars each month . If Congress phases out these over-payments, premiums and benefits in PFFS plans can change considerably.

Although other states are reporting a rash of deceptive marketing practices, these problems are surfacing at a lower rate in Vermont. But Ireland says that lower income beneficiaries should be especially wary of aggressive sales pitches. If you are dual-eligible - enrolled in Medicaid as well as Medicare - you do not have to pay co-pays whether or not you have an MA plan. That means that you may not benefit at all from an MA plan once you factor in its extra premium.

"Buyer beware," says Ireland. "Medicare Advantage does not supplement original Medicare. It replaces it.  Be clear about which services you need, how the various plans compare to each other, and how they compare to what you already have." 

• For more information about Medicare Advantage, go to www.medicare.gov
• For assistance in choosing a health insurance plan, contact the State Health Insurance Assistance Program at CVAA   

Barbara Leitenberg writes on senior issues for the Champlain Valley Agency on Aging. This article originally appeared in the Burlington Free Press.