The Drawbacks Of Medicare Advantage Plans Can Become Apparent When Serious Illness Or Injury Strikes
Medicare Advantage plans are attracting seniors with their appealing price tags and promise of comprehensive health coverage in one convenient package. But are these plans actually a disadvantage for people with serious health problems?
Thats the question raised by a string of recent studies. A 2017 review by the U.S. Government Accountability Office, for example, found that in some Advantage plans, enrollees in poor health were substantially more likely to dump the plan than those in good health. A recent study by Brown University researchers found that Medicare Advantage enrollees are more likely to enter lower-quality nursing homes compared with people on original Medicare. Earlier studies have also found that people using high-cost services such as nursing-home care disproportionately switch from Medicare Advantage to original Medicare.
Medicare Advantage tends to work for people when they are relatively well, says Judith Stein, executive director of the Center for Medicare Advocacy. But if they become ill or injured and really need a significant length of care, theyre not as well served.
Theres a reason enrollment in MA plans continues to increase year over year: It works, says Cathryn Donaldson, spokesperson for Americas Health Insurance Plans, which represents insurers offering Advantage plans. Advantage enrollees, she says, are receiving better care, better service and better value.
Enroll In A Medicare Advantage Plan Today
Once youre enrolled in Original Medicare, you can sign up for a Medicare Advantage plan.
Compare Medicare Advantage plans that may be available in your area and speak with a licensed insurance agent who can help you sign up for a Medicare Advantage plan thats right for you.
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About the author
Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelors degree in journalism. He currently lives in Raleigh, NC.
Where you’ve seen coverage of Christian’s research and reports:
MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts enrollment in any plan depends upon contract renewal.
Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE , 24 hours a day/7 days a week or consult www.medicare.gov.
What Does Medicare Advantage Cover Relative To Original Medicare
Health insurance companies that provide Medicare Advantage plans are required by law to deliver at least the same coverage as Part A and Part B insurance that you would receive under Original Medicare.
However, there are some differences to consider when you are deciding whether you want to receive your coverage through Original Medicare versus Medicare Advantage:
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What Is Right For You
Everyone is different, so there is no standard answer. Both types of coverage are reputable health coverage. Just make sure you are considering the total costs and your healthcare needs to get the big picture before making any decisions.
Some people like the security of a MOOP with Medicare Advantage, even though some plans incur heavy spending before you reach the cap. Set aside money for copays and coinsurance to help make sure you are covered in the event of a chronic illness.
If you are a frequent traveler, a Medicare Advantage plan may not be the best choice due to the networks. If you travel south in the winter, Original Medicare is possibly your cheapest bet. Paired with a Medigap plan, this will provide you will more predictable costs, and it will be more manageable for you to find providers.
For those on a budget, Medicare Advantage with a Part D plan may be appealing it is convenient, and all of your benefits are covered in one monthly premium.
In the end, it is always good to consult with a professional, such as someone here at Medicare Pathways, to see what plans are available in your area. That way, we can help you compare and decide between all of your options to help you find the best coverage fit for your health needs and your budget and avoid any late enrollment fees.
Compare your Health Plans Options
Speak with a licensed insurance agent to compare Medicare health plan options and find the plan that meets your financial and medical needs.
Cons Of Medicare Advantage
With Medicare Advantage, the benefits are different from plan to plan. You still have to pay your Part B premium. The biggest downfall to Medicare Advantage is the limited doctor networks. When you need to see a specialist with a small network, access to care can be more challenging. Another con to Part C plans is the high cost per service. Yes, zero to low premiums are appealing, but when you add the additional out of pocket costs you pay as you use the benefits, some find its just not worth it.
Unlike Original Medicare, Part C plans come with annual coverage changes. The plan that works for you now, may not work for you next year. These plans also do not travel with you. Lastly, the Maximum Out Of Pocket limit can still break the bank.
Now that we went over a few of the pros and cons of both Original Medicare vs Medicare Advantage, lets compare doctor visits, covered services, and costs a little more in detail.
Doctor Visits
When you have Original Medicare, you can see any doctor or specialist that accepts Medicare. You dont need a referral to see a specialist either. Since plans dont change annually, you wont need to worry about your doctor leaving the plans network.
When you have Medicare Advantage, your coverage will be very similar to your employer group coverage. The majority of them are health maintenance organizations and preferred provider organizations.
Covered Services
Costs
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Pros Of Original Medicare
With Original Medicare, the benefits are identical from person to person. There are no copays, no waiting periods, and no pre-existing condition limitations. There are also no networks. You can see any doctor that accepts Medicare. Any out of pocket costs will remain the same regardless of the provider you choose to receive care from. Your coverage will travel with you across the United States.
Can You Enroll In Medigap
If youre switching from Medicare Advantage to Original Medicare, you can also purchase a plan Medicare Supplement plan. This kind of plan, also known as a Medigap policy, pays for gaps in Medicares coverage.
For instance, Medicare Part B pays 80% of covered costs after you pay your annual deductible. A Medigap policy would pay the remaining 20% due. But if youve missed your Medigap Open Enrollment Period, an insurer could deny you coverage due to your health history.
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Original Medicare Vs Medicare Advantage: How To Choose
Choosing between Original Medicare and Medicare Advantage is tough. Find out how they compare.
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Your decision regarding Medicare plans will make all the difference in how you get your healthcare and how much youll pay for it.
The year you turn 65 is marked by a big decision. This is the year that youll need to enroll in one of many Medicare options.
The two main ways to get coverage are through Original Medicare and Medicare Advantage . Since your choice will affect what doctors you are approved to see, what services you receive, and how much youll pay, theres a lot on the line.
How Do They Differ On Cost
Having Medicare Part A and Part B without any supplemental coverage can be costly because there is no cap for cost-sharing or no limit on out-of-pocket expenses.
If you dont need much medical care and dont have many prescriptions, you might find Original Medicare to be cost-efficient. Original Medicare has copayments for Part A services and a 20% coinsurance for most Part B services. While a Medicare beneficiary has the option to enroll solely in Original Medicare, they should be informed about the penalty if they dont enroll in a Part D plan when eligible, and then decide much later to enroll in a Part D plan.
With Medicare Advantage, enrollees pay copayments, though annual out-of-pocket costs are capped at $6,700. That can be helpful for those with complicated conditions who get regular, expensive medical care. Premiums for Medicare Advantage plans range from $0 to more than $100. Plans with no or low premium can have higher copayments and/or deductibles than plans with higher premiums.
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Why Choose Medicare Advantage
Medicare Advantage plans must offer benefits comparable to original Medicare. The government regulates these plans, ensuring that they meet certain basic care requirements. The costs and copays for various services, however, may be different. For some people, Medicare Advantage is a better choice. You might choose Medicare advantage because:
- There are more options. In 2018, the average Medicare beneficiary could choose from 21 plans, though some regions offered even more choices.
- Premiums may be lower on some plans. Some even offer $0 premiums, though this usually means you’ll pay higher copays.
- There is usually prescription drug coverage. Original Medicare does not cover prescription drugs unless you enroll in Part D. In 2019, 90% of Medicare Advantage policies offered prescription drug coverage.
- You may pay less for expensive services. Medicare Advantage plans are legally required to limit your out-of-pocket maximum costs. With original Medicare, you keep paying costs no matter how much you spend. In 2020, the out-of-pocket maximum for most Medicare Advantage costs was $6,700.
- There is often coverage for services original Medicare will not fund. Each plan is different, so it is important to compare and review plan documents. However, many Medicare Advantage plans offer dental or vision coverage. Original Medicare, by contrast, covers only medical and hospital care.
Are My Comments Too Negative
Your choice of health coverage is a tricky subject. People tend to email me when they have negative experiences. So, my anecdotally-based comments may be more negative than warranted. There are many different Medicare Advantage plans. Some may be better than others.
If anyone has any clinical studies on this subject or more positive experiences, please let me know.
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Finding Part D Drug Insurance
To get started, find the plans available in your zip code. Once you have created an account at Medicare.gov, you can enter the names of your drugs and use a convenient tool that allows you to compare plan premiums, deductibles, and Medicare star ratings.
If you dont take many prescription drugs, look for a plan with a low monthly premium. All plans must still cover most drugs used by people with Medicare. If, on the other hand, you have high prescription drug costs, check into plans that cover your drugs in the donut hole, the coverage gap period that kicks in after you and the plan have spent $4,130 on covered drugs in 2021.
Main Differences Of Medicare And Medicare Advantage
Original Medicare is run by the federal government and is overseen by the U.S. Centers for Medicare & Medicaid Services . Medicare Advantage is an alternative to Original Medicare. These plans are sold through private insurers who contract with CMS to provide coverage.
Who provides coverage is the biggest difference between the two, but there are several more that you should consider before deciding which option is right for you.
Biggest Differences Between Original Medicare and Medicare Advantage
Most in the United States accept Original Medicare. The federal government also limits how much health care providers can charge people on whether the doctors or hospitals participate in Medicare or not.
All must cover the same things Original Medicare covers. But Medicare Advantage plans may also cover other benefits such as hearing, vision, dental and prescription drug coverage.
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Medicare Advantage Plans Offer Benefits Not Included In Original Medicare
I said I would include a sixth advantage to Medicare Advantage plans, and this is it. Most Medicare Advantage plans offer additional benefits. The most common extra benefit bundled with private health plans is Medicare prescription drug coverage, also known as a Medicare Part D plan. And, for many people, the extra benefits really add up.
This is particularly true if you are exceptionally healthy and rarely see your doctor, except for your annual wellness checkup. For these people, plans that bundle prescription drug coverage, routine dental, vision, and hearing care, and gym memberships, like Silver Sneaker, add up to huge savings.
For people with chronic health conditions, who do not receive copayment and other financial assistance from the government or retiree benefits, the additional coverage options are a drop in the bucket, benefit-wise, compared to the out-of-pocket costs.
What Is Original Medicare
Original Medicare is a fee-for-service health plan offered by the federal government. It includes two parts: Medicare Part A and Medicare Part B.
Medicare Part A
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Inpatient hospital care
Medicare Part B
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Doctor appointments
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Preventative care
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Outpatient care
But although Original Medicare offers many services, it doesn’t cover everything. Typically, Medicare only covers about 80% of healthcare costs within the U.S. These plans don’t pay for routine hearing, routine dental, routine vision, or long-term care.
Original Medicare also doesn’t cover prescription drugs. If you have Original Medicare and need prescription drug coverage, you must purchase Medicare Part D prescription drug coverage as a standalone policy.
There’s also the option of buying a Medicare Supplement insurance plan to help cover some of the costs that Original Medicare doesn’t.
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How Much Is A Medicare Advantage Plan
Medicare Advantage Part C plans are sold by private health insurance companies. Monthly premiums will vary depending on the covered benefits, but you can expect premiums between $0 to $200 a month.
These plans feature deductibles, copays, and coinsurance. You’ll need to shop around and compare plans to limit the amount you pay out-of-pocket each year.
Pros of a Medicare Advantage Plan
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Includes additional benefits such as drug coverage, routine vision, routine hearing, routine dental, and wellness programs
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Although some plans charge a monthly premium in addition to a Part B premium, what you pay could be cheaper than buying Medicare Supplement insurance to accompany Original Medicare
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Part C provides all-in-one Medicare coverage
Cons of a Medicare Advantage Plan
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There’s less freedom to choose your own doctors, hospitals, and pharmacies
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Part C plans are area specific. If you move, you’ll have to enroll in a new plan
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You typically need a referral to see a specialist
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You cannot combine Medicare Part C with Medicare Supplement insurance
Local Conditions And Convenience
In some areas where physicians and hospitals are scarce, its important to check out both the networks of available Medicare Advantage plans and the locations of providers who accept regular Medicare. Are the doctors accepting new patients? Will you have to travel far to see a provider or be treated in an emergency room? Advice from local professionals, neighbors, and licensed insurance brokers can help you find Medicare Advantage plans that do business in your area. Compare plans to find one that may suit your needs.
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If You Lose Your Medicaid Eligibility:
If youre covered by both Medicare and Medicaid and then you lose eligibility for Medicaid, you can switch from Medicare Advantage to Original Medicare up to three months from the date you lose Medicaid eligibility, or the date youre notified, whichever is later.
- If youre told in advance that youll lose your Medicaid coverage for the following year, you can switch to Original Medicare between January 1March 31.
Changing From Medicare Advantage To Original Medicare
Changing from Medicare Advantage to Original Medicare is a very simple process once youre ready and eligible to switch. There are three ways you can make the change:
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Can I Switch From Medicare Advantage To Original Medicare
The answer is yes. You can return to Original Medicare during the Annual Election Period or the Medicare Advantage Disenrollment Period. Be aware, though, that adding a Medigap plan requires answering health questions in most states, and the company can decline your coverage based on your health. This is important to consider before switching any coverage.
Medicare Advantage Plans Start At $0/month
In 2020, nearly two-thirds of Medicare Advantage beneficiaries paid no premium for their plan.Youll still be required to pay your Medicare Part B premium. That said, it may be an enticing option for those who dont want to juggle paying multiple premiums each month.
If youre interested in seeing Medicare Advantage Plans with $0 monthly premiums, Ensurem offers an online quote tool thatll allow you to compare plans in your area.
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The Average Cost Of A Medicare Advantage Plan
Some Medicare Advantage plans may have lower out-of-pocket costs than Original Medicare, and some have a $0 monthly premium. Here are a few questions to consider before purchasing a plan.
- Does the plan have a monthly premium?
- Many have a $0 premium.
- Some pay your Part B premium.
- If you choose a plan with a premium, it will be paid separately from your Part B premium of $148.50 .
Once youre enrolled in a Medicare Advantage plan, it becomes your primary insurance. The company handles paying all your claims. And every year, the cost of your plan will probably change. The plan provider sets the amounts charged for premiums, deductibles and services. An Annual Notice of Change is mailed to you each September to be effective Jan. 1.
Factors like location play a major role in determining the cost of a Medicare Advantage plan. Costs are typically lower when you use providers in your plans network and service area. To find the specific cost of a Medicare Advantage plan in your zip code, visit Medicare.gov.
