Value-Based Care & Medicare Advantage for Adults 65+

1. Understand what value-based care means

Value-based care focuses on care quality and patient experience. Programs put this approach into practice in different ways. ^[2] Some payment programs reward providers for quality rather than the number of services delivered. ^[13]

Evidence-based practice means using reliable research, your clinician's judgment and your values when making decisions. A study can guide the discussion, but your health history, needs and choices still matter. ^[1]

Medicare Advantage is health coverage. Value-based care is an approach to care. They are not the same. Coordinated care also exists in Original Medicare through arrangements such as accountable care organizations, which are not Medicare Advantage plans. ^[3][4]

Ask your team: What does this approach change about the care I receive?

2. Start with what matters to you

A useful care plan connects treatment with the activities and relationships you want to maintain. Your priorities may change, so revisit them with your care team. ^[12]

Try finishing one of these sentences before your appointment:

• "I would like to feel more confident when I…"
• "The part of my daily routine that is hardest is…"
• "A treatment concern I want to discuss is…"

You might describe getting to a place of worship, preparing a favorite meal or keeping up with grandchildren. Explain what is difficult and what support you already have. Ask which next step fits your situation and how you will know whether it is helping.

Independence does not have to mean doing everything alone. You can ask a family member or caregiver to join the conversation if that is your preference.

3. Make prevention and ongoing care personal

Ask whether you are due for a Medicare Annual Wellness Visit to develop or update your prevention plan. This visit is different from a routine physical exam. Additional evaluation, tests or treatment may involve separate costs. ^[5]

Bring up symptoms and changes in daily function when scheduling, so the office can help you plan the right kind of visit. Useful questions include:

• Which health concern should we address first?
• Why is this test or treatment recommended for me?
• What could it change about my care?
• How and when will I receive the results?

If you live with several conditions, describe how the care plans fit into one day. Tell your team when instructions seem to conflict or the plan feels difficult to follow. Ask for one clear set of next steps rather than guessing which instructions take priority.

4. Keep medicines and care instructions connected

Keep an up-to-date list of prescriptions, medicines bought without a prescription, vitamins and supplements. Include doses, schedules and who prescribed them. Ask a clinician or pharmacist about side effects, possible interactions and any difficulty following the instructions. Do not stop or change prescribed medicines on your own. ^[6]

For your next visit, put your medicine list and questions in one folder or on your phone. Note what you are actually taking, including anything that was recently changed by another clinician.

Then ask: Who is keeping my care plan up to date? Which office should I contact about a refill, test result or referral? If a medicine is too expensive, hard to obtain or difficult to take, say so. Ask what options you can discuss with the prescriber.

5. Plan the transition after a hospital stay

Before leaving the hospital, ask for written instructions about medicine changes, warning signs, who to call and follow-up visits. Discuss help or equipment you may need at home. Follow your discharge team's recommended timing and bring the instructions to your clinic visit. ^[10]

A review of 126 trials found that some structured hospital-to-home programs reduced return hospital stays after discharge. Results differed by program and follow-up time. The review did not find clear evidence of better quality of life. The review combined different adult populations and programs; it does not establish results for Hernandez Health or for every Medicare Advantage patient. ^[9]

Use your follow-up visit to clarify anything that is missing or confusing. If you are unsure whom to call, ask before going home. For a medical emergency, call 911. Avoiding a hospital stay must never mean delaying necessary emergency care.

6. Support movement and everyday well-being

If you have fallen or feel unsteady, ask about an exercise or physical-therapy plan that fits your abilities. The U.S. Preventive Services Task Force recommends exercise interventions for adults 65 and older who live in the community and have an increased risk of falls. ^[7]

In the LIFE trial, a structured activity program helped preserve walking ability in adults ages 70–89 who were not physically active, had physical limitations and could walk at the start. That does not mean every exercise program prevents disability or hospitalization. ^[8]

Healthy aging also includes mental, emotional and social well-being. Discuss concerns about mood, sleep, memory, nutrition or loneliness—not only physical symptoms. ^[11]

Ask how a suggested change fits your goals. You do not need to copy someone else's activity plan or make every change at once. Work with your team on a manageable next step.

7. Check coverage and ask for clear communication

Your plan's network, cost, referral and approval rules still apply. A value-based care label does not make every service free. Confirm your coverage with your plan. ^[3]

Ask for instructions in language you understand. Tell the office your preferred language and whether you want a family member or caregiver involved. If your care instructions are unclear, try: "Let me explain what I understood. Is this what you want me to do?"

For more about Medicare visits and coverage checks, read our Medicare Advantage primary care guide.

8. Information for California-licensed insurance agents and brokers

Helping a Medicare Advantage client age 65 or older find senior primary care in the Inland Empire or High Desert? Use this guide to discuss coordinated care and personal health goals.

Have the client's health plan verify the specific plan, clinic, clinician, network status, any required primary care provider or medical group assignment, and effective date. Then confirm new-patient availability with the clinic. A company name or logo alone does not establish coverage. ^[14]

With your client's permission, contact the preferred clinic in Perris, Hemet, Ontario or Victorville. Ask about Spanish-speaking provider availability.

Patients can check a California insurance professional's license. ^[15]