What Are The Pros And Cons Of Medicare
- Like many things, Medicare has its advantages and disadvantages. Learn about some of the pros and cons of Medicare, including the federally administered Medicare program and private Medicare plans.
Youve probably heard about some of the advantages and disadvantages of Medicare. Like so many things, Medicare has both pros and cons, both of which we will highlight below.
Option : Original Medicare
- Medicare is primary and Medi-Cal is secondary. In Original Medicare, also known as fee-for-service, it is important to present providers with both Medicare and Medi-Cal cards. With Original Medicare you can choose any medical provider that accepts Medicare and Medi-Cal, no referrals to a specialist is needed.
- In addition to the Medicare and Medi-Cal card, beneficiaries also have a CalOptima Member Identification card and a Part D Prescription Drug Plan card.
- Medi-Medi beneficiaries that do not enroll in a Part D Plan or a Medicare Advantage Plan will automatically be enrolled in a Part D benchmark plan. Medi-Medi beneficiaries are automatically eligible for , the program that helps pay for prescription drug plan co-payments.
The Share Of Medicare Beneficiaries In Medicare Advantage Plans Varies Widely Across Counties
The share of Medicare beneficiaries enrolled in Medicare Advantage varies widely across counties. For example, in Florida, 56% of all Medicare beneficiaries in the state are enrolled in Medicare Advantage, ranging from 19% in Monroe County to 78% in Miami-Dade County. In Ohio, 52% of all Medicare beneficiaries are enrolled in Medicare Advantage, with the share ranging from 30% in Mercer County to 64% in Stark County .
In 2022, one in five Medicare beneficiaries live in a county where at least 60 percent of all Medicare beneficiaries in that county are enrolled in Medicare Advantage plans . That is substantially more than in 2010 when just 3 percent of the Medicare population lived in a county where 60 percent or more of Medicare beneficiaries were enrolled in a Medicare Advantage plan . Many counties with high Medicare Advantage penetration are centered around relatively large, urban areas, such as Monroe County, NY , which includes Rochester, and Allegheny County, PA , which includes Pittsburgh. However, some urban areas, such as Baltimore City, MD , Charleston, SC , and Cook County, IL have lower Medicare Advantage enrollment.
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Disadvantages Of Medicare Advantage
While most people are happy with their Medicare Advantage coverage, there are some drawbacks to these plans compared to traditional Medicare.
Limited service providers
If you select one of the more popular Medicare Advantage plan types, such as an HMO, your provider options may be limited. You will generally pay more if you choose an out-of-network provider with these plans.
Other plan types give you more provider freedom, though those plans may have higher premiums and fees like copays and deductibles.
Complex plan offerings
Using Medicare to discover a planning tool, youll realize that various Medicare Advantage plan possibilities depend on your ZIP code but for some people, all these alternatives can feel overwhelming.
To help you decide which Medicare Advantage plans are right for you, read our article on Tips for Choosing a Medicare Advantage Plan.
Extra coverage costs
Part A & B of Original Medicare have a premium, deductible, and coinsurance, as well as any Part D or Medigap costs.
These costs are frequently consolidated in Medicare Advantage plans, but you may be charged additional fees. Many Medicare Advantage plans, for example, include drug deductibles and copays for specialist visits.
What Does A Medicare Advantage Plan Cost
Depending on your Medicare Advantage plan, the costs you pay out-of-pocket can vary:
- You may pay a deductible, a certain amount you must meet before your plan begins to pay.
- There may be copays for doctor visitsthis is a flat fee usually due at the time of the visit.
- You may have to pay a share for lab services and medical equipment.
- You will pay a monthly plan premium if there is one.
- You will continue to pay the Original Medicare Part B monthly premium, as well.
- Additional coinsurance or copays if you see providers outside your plan network.
To help control your costs, make sure you understand the terms of your plan and the out-of-pocket costs you may be required to pay.
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Medicare As Social Insurance For The Country
As a program funded primarily through taxes, Medicare can be considered a social welfare program as well as a social insurance program. The word social conjures up different images to people depending on where they fall along the political spectrum. Conservatives tend to believe in the power of individual responsibility, equating government programs with unnecessary handouts. Liberals typically support social programs on the basis that these programs are designed to enhance society in some way.
Wherever you fall along the political spectrum, youre probably aware that Medicare operates as a social program unlike other government programs. Serving a specific need and doling out only what beneficiaries pay into the system, Medicare offers healthcare coverage for seniors. In many ways, this idea can be seen as a positive use of socialization.
Medicare works on the basis that people pay into the system throughout their working years so that they can retire and still get health insurance. Like other social programs, the Medicare system operates on widespread distribution of funds. Unlike other social welfare programs, most, if not all of the beneficiaries have contributed in a substantial way prior to receiving the benefits of the system.
Medicare Advantage Plans Often Provide More Benefits Than You Would Receive Under Original Medicare
Medicare Advantage plans must offer at least the same level of coverage as Medicare Part A and Part B and many plans offer added benefits. These may include coverage for routine vision care, hearing aids, routine dental care, prescription drug coverage, and fitness center membership.
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How Do Medicare Advantage Plans Work
A Medicare Advantage is another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. If you join a Medicare Advantage Plan, you’ll still have Medicare but you’ll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare.
These “bundled” plans include
, and usually Medicare drug coverage .
What About Medicare For All
Medicare for All, also known as universal or single-payer healthcare, is a concept youve heard about but might not know exactly how it works. There are different versions and proposals, but at its core, it means that nearly all Americans would have access to the type of government-funded healthcare currently provided only to those over 65 or disabled.
In some Medicare for All proposals, all Americans would be covered by the government program and private health insurance would be limited to offering only supplemental insurance for procedures not covered by the government program such as elective plastic surgery or hearing aids. Other versions maintain the private insurance industry but provide the government program as an option.
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Medicare Advantage Plans Provides More Benefits
Medical Advantage Plans are an upgrade to Original Medicare because they offer at least the same degree of coverage as Medicare Part A and Part B, and many plans provide enticing add-ons. These may comprise coverage for routine ocular care, hearing aids, oral care, prescription drug coverage, and gym membership. There are even some that connect you to wellness coaches on your smart device to enable you to attain your health goals.
What Are The Advantages And Disadvantages Of Medicare Advantage Plans
What Are The Advantages And Disadvantages Of…
Every year, millions of Americans enroll in Medicare Advantage plans. This year, you may be among them, and you will want to feel confident that you are picking the best plan for you.
With this guide, we will review some of the basics of the Medicare Advantage program. Then, we will compare them to Original Medicare and Medicare Supplement insurance plans. Lastly, we will give you some tips on how to know if Medicare Advantage fits your needs.
Medicare Advantage plans close the gaps in Original Medicare with small copays and coinsurance.
Exercise Caution With Zero
Health insurers will flood the Medicare Advantage market again this fall with enticing offers for plans that have no monthly price tag.
The number of so-called zero-premium plans has been growing for years, and they can appeal to retirees who live on fixed incomes. Experts say shoppers should exercise caution, because they might find better coverage at a relatively small monthly cost.
Its not a one-size-fits-all program, said Melissa Brenner, a broker in Charlotte, North Carolina. You dont want to look at a zero plan and just enroll in it.
Medicare Advantage plans are privately run versions of the governments Medicare program for people who are age 65 and older or have certain disabilities. The annual enrollment window for 2023 Medicare Advantage coverage opens next week.
A closer look at the coverage:
A GROWING OPTION
Nearly seven out of 10 people who enrolled in an individual Medicare Advantage plan with prescription drug coverage for this year opted for no-premium plans, according to the Kaiser Family Foundation, a nonprofit that studies health care issues. Thats up from around five in 10 in 2015.
Kaiser also found that 98% of people eligible for Medicare had access to an Advantage plan with drug coverage that charged no premium.
Theyre everywhere, said Bob Rees, vice president of Medicare sales for the online insurance broker eHealth.
KNOWING THE CATCH
The adage that nothing in life is free applies here.
WHAT TO CONSIDER
How To Choose A Free Medicare Advantage Plan
You can use Medicares plan comparison tool to search for Medicare Advantage plans. Once you enter your ZIP code and answer a few questions, you can get prices for plans available to you. Although many plans show a $0 premium, its important to understand the other costs youll pay if you need care.
Here are other questions to consider:
Are your doctors in-network? Many Medicare Advantage plans require you to get care from medical providers and hospitals in their network.
Are your prescriptions covered? Prescription coverage can change from year to year, so check a plans coverage each year during Medicare open enrollment.
What other benefits are available? Does the plan offer dental or hearing coverage? How much?
You may find that two $0-premium plans are very different, so make sure youve done some comparisons before you sign up.
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Medicare Advantage Plans Offer Coordinated Medical Care
Many Advantage policies are offered based on systems that leverage on coordinated medical care. This allows any provider that you visit to maintain communication with one another to provide you with synchronized, efficient medical care. One study revealed that coordinated care was linked with higher patient rankings and good staff experiences.
Medicare Advantage Plans Have Specific Service Areas
Most Medicare Advantage plans have regional networks of participating providers. To enroll, you must reside in the Medicare Advantage planâs service area at least 6 months of the year. If you divide your time between homes located in different areas, this requirement may be difficult to meet.
The bottom line is that Medicare Advantage plans may provide more affordable coverage than you would receive otherwise. The trade-off is that you have to follow the Medicare Advantage planâs rules to receive payment for covered services.
Do you have other questions about Medicare Advantage? Call us and speak with a licensed insurance agent about finding Medicare Advantage plans in your area and your Medicare coverage options. Or just enter you zip code on this page.
Medicare information is everywhere. What is hard is knowing which information to trust. Because eHealthâs Medicare related content is compliant with CMS regulations, you can rest assured youâre getting accurate information so you can make the right decisions for your coverage.Read more to learn about our Compliance Program.
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Beneficiaries Enrolled In Medicare Advantage And Traditional Medicare Look Similar After Separating Out Snps
After excluding beneficiaries in SNPs, beneficiaries enrolled in traditional Medicare do not differ significantly from Medicare Advantage enrollees on age, income, or receipt of a Part D low-income subsidy , which helps low-income individuals pay for prescription drugs . However, beneficiaries in traditional Medicare are significantly more likely than Medicare Advantage enrollees to reside in a nonmetropolitan area, as well as more likely to live in a long-term-care or residential facility.
Beneficiaries in SNPs are different. Given the eligibility criteria for these plans, it is not surprising that enrollees tend to have significantly lower incomes and a greater likelihood of receiving Medicaid benefits or LIS than other Medicare beneficiaries. Enrollment in SNPs for people who require an institutional level of care has been growing rapidly, leading to a similar share of SNP enrollees and beneficiaries in traditional Medicare living in a long-term-care facility.8
Racial/ethnic distribution of enrollees. The racial and ethnic distribution of beneficiaries in traditional Medicare and Medicare Advantage is similar, after separating SNPs from other Medicare Advantage plans . Most beneficiaries in traditional Medicare and Medicare Advantage plans identify as white. However, SNP enrollees are significantly more likely to identify as Hispanic or Black.
Health Insurance Coverage For People Who Need It
Medicare is the single largest health insurance program in the U.S., providing hospital insurance and medical insurance coverage to more than 60 million Americans.
If Medicare didnt exist, tens of millions of seniors and people with disabilities would have to rely on some form of private health insurance in order to have suitable coverage, something that might not be affordable for many people.
Medicare Advantage Plans May Limit Your Freedom Of Choice In Health Care Providers
With the federally administered Medicare program, enrollees can generally go to any doctor or facility that accepts Medicare and receive the same level of Medicare benefits for covered services. In contrast, Medicare Advantage plans may be more restricted in terms of their provider networks. If you go out of network, your plan may not cover the medical costs, or your costs may not apply to your out-of-pocket maximum.
Medicare Payment And Delivery System Reform
Policymakers, health care providers, insurers, and researchers continue to debate how best to introduce payment and delivery system reforms into the health care system to tackle rising costs, quality of care, and inefficient spending. Medicare has taken a lead in testing a variety of new models that include financial incentives for providers, such as doctors and hospitals, to work together to lower spending and improve care for patients in traditional Medicare. The goals of these financial incentives generally link a portion of Medicareâs payments for services to âvalueâ as determined by providersâ performance on spending and quality targets.
Accountable Care Organizations are one example of a delivery system reform model currently being tested within Medicare. With over 10 million assigned beneficiaries in 2018, ACO models allow groups of providers to accept responsibility for the overall care of Medicare beneficiaries and share in financial savings or losses depending on their performance in meeting spending and care quality targets. Other new models include medical homes, bundled payments , and initiatives aimed to reduce hospital readmissions.
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What Are The Disadvantages Of Medicare Advantage Compared To Original Medicare
There are two disadvantages to Part C plans:
- Network and referral restrictions
Some Medicare Advantage plans have a monthly premium. In this case, you are paying your standard Part B premium plus a monthly premium for your Part C coverage.
Medicare Advantage plans almost always have a network of preferred or required providers. It is important to note that you must use providers that are covered by the plan.
However, many Medicare Advantage plans do not have a monthly premium. Those that do often have quite low premiums, which would be comparable to the premium you would pay for standalone Part D coverage. Cost is only a very slight disadvantage, and it only applies if your MAPD plan does indeed have a premium.
Medicare Advantage plans almost always have a network of preferred or required providers. It is important to note that you must use providers that are covered by the plan. Also, you will often need a referral from a primary care physician if you want to see a specialist.
With Original Medicare, there are no set networks. This means that you can see any doctor in the nation that takes Medicare patients. You also usually wont need any kind of referral in order to do so.
Medicare Advantage Plans Offer Additional Coverage
More and more Americans sign up for Medicare Advantage plans each year, and enrollment is expected to keep growing in the future. In fact, enrollment was at 24.1 million in 2020.2
Medicare Advantage plans offer beneficiaries an alternative way to get Medicare benefits through plans sold by private insurance companies that contract with the Centers for Medicare & Medicaid Services .
You get all the Medicare program benefits of Part A hospital insurance and Part B medical insurance, together known as Original Medicare,* when you enroll in Medicare Advantage. Plus, many Medicare Advantage plans can also provide additional benefits at a minimal cost. These services are essential to older Americans who may otherwise go without them.
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What Does Every Senior Need To Know About Medicare
The Benefits of Medicare. Most Americans, adults in particular, are familiar with the basic premise of the Medicare program operating in this country. However, those who are not taking advantage of the coverage Medicare offers may not be familiar with all the Medicare benefits that can be provided. The overall goal of Medicare is to provide senior citizens and other individuals