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What’s Wrong With Medicare Advantage

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Durable Medical Equipment And Home Modifications

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Original Medicare only covers medical equipment that is considered durable which is generally defined as something that must be usable at home for at least three years.

Some examples of durable medical equipment include oxygen equipment, nebulizers, infusion pumps, wheelchairs, and others. However, Original Medicare does not include home modifications.

MA plans can cover this providing coverage for modifications such as wheelchair ramps, bathroom support bars, stair lifts, automatic doors, and other similar items.

Reason : Hospitalization Costs More Not Less

In many cases and with many plans, this is true.

In fact, a recent Kaiser Family Foundation study shows that half of all Medicare Advantage enrollees would incur higher costs than beneficiaries in traditional MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage…. for a 5-day hospital stay. Thats shocking, but given the rising cost of hospitalization, its also understandable.

This fact also underscores the need to carefully scrutinize Medicare Advantage plans annually so you are not surprised by the bills. Ambulance, emergency room, diagnostic, hospitalization, and inpatient medication copays add up very fast.

IMPORTANT: If you are getting your Medicare benefits for the first time, and you have a chronic health condition that necessitates frequent care, pay careful attention to Medicare Advantage hospitalization costs. If you can get a Medicare supplement during your Medicare supplement guaranteed-issue rights period, your hospitalization costs over time will generally be lower.

What If You Do Need An Expensive Medication

The prices of most brand name medications are more than most people can easily afford. Even with insurance, the copays for some of these medications can be quite steep . So, if you are prescribed a brand name medication, first ask your doctor if there is an inexpensive alternative to that medication. Often there is, but most doctors dont consider price when writing prescriptions .

If there is no inexpensive alternative for a medication that youll need to take regularly, you should definitely buy prescription drug coverage. If you need the medication for only a short term, the doctor might have some free samples to start.

The main problem with having prescription drug coverage before needing it is that youll never know if the plan you have will cover a new medication should you need it. Most prescription drug plans have their own list of approved medications and, if the medication youre prescribed isnt on your insurance companys list, theyll do anything they can to avoid paying for it. Whats more, a covered medication might still have an obscenely high copay thats only slightly less than the cash price for that medication .

Buying prescription drug coverage isnt the same as buying other types of insurance like, for example, fire insurance. Its really more like buying a fire insurance policy that only covers you if the fire starts at a certain time of day or in a certain room of your house.

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Does Advantage Have A Leg Up

Under President Trump, some critics contend, the Centers for Medicare and Medicaid Services, which administers Medicare, has become a cheerleader for Advantage plans at the expense of original Medicare.

Advocates and some lawmakers have complained about bias in educational and outreach materials on enrollment, and in public statements about Advantage by the agencys administrator, Seema Verma.

One flare-up was provoked by a draft release of the 2019 Medicare & You handbook, an important annual guide mailed to all enrollees and made available online. Advocates and some lawmakers criticized language describing Advantage as a less expensive alternative to original Medicare. But despite the data on patients average spending, no figures are available on their specific out-of-pocket costs.

We know absolutely nothing about what people actually pay for services, Dr. Neuman of Kaiser said. If someone is really sick and uses a lot of covered services, they could pay less with traditional Medicare coupled with a Medigap policy than they would in a Medicare Advantage plan, even after taking into account Medigap premiums.

The handbooks language was revised before its final release, but communications from the Centers for Medicare and Medicaid Services during last falls Medicare enrollment period do appear to promote Advantage plans.

There does seem to be a strong philosophical preference for private insurance over public programs in this administration, Dr. Neuman said.

Expanding Medicare Advantage Is A Bad Idea

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In an op-ed for Health Affairs, Ken Terry and David Muehlestein explain why expanding the Medicare private insurance option to everyone or Medicare Advantage for All is a bad idea. Among other things, we cant distinguish among Medicare Advantage plans or prevent plans from jeopardizing the health and well-being of their members through narrow networks with poor quality providers, cumbersome administrative hurdles, inappropriate delays and denials of care and high out-of-pocket costs. According to one recent NBER paper by Jason Abaluck at Yale et al., picking the wrong Medicare Advantage plan could kill you.

Heres what we know:

Heres what we dont know:

Heres more from Just Care:

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How Are Medigap And Medicare Advantage Different

Medicare Supplement Insurance plans can help provide coverage for some of the out-of-pocket costs that are tied to Original Medicare. These costs can include Medicare deductibles, coinsurance, copayments, excess charges and more.

Medicare Advantage plans provide the same benefits of Original Medicare combined into one single plan. Many Medicare Advantage plans may also offer additional coverage for things like dental, vision, hearing, prescription drugs and more.

To put it simply, Medigap plans are used in addition to Original Medicare and provides coverage for health care expenses. Medicare Advantage plans are used as an alternative to Original Medicare and provides coverage for health care services.

Health Care Costs Vary Based On Your Medical Care

An important downside is that your total costs will fluctuate based on how much health care you need.

Many beneficiaries assume that Medicare Advantage plans are cheaper alternatives because their monthly premiums are often low or even nonexistent. But most of the costs with Medicare Advantage plans come from copays, coinsurance, deductibles and other out-of-pocket costs that emerge as part of the overall care process.

And these costs can quickly escalate. If you need expensive medical care, you could end up paying more out of pocket than you would with Original Medicare.

Example of how medical expenses compare for a hospitalization

A hospitalized beneficiary covered under a traditional Medicare plan will have to meet a Plan A deductible of $1,480. But after that deductible is met, there are no more costs until the 60th day of hospitalization.

Most Medicare Advantage plans have their own policy deductible. But the plans start charging copays on the first day of hospitalization. This means a beneficiary could spend more for a five-day hospital stay under Medicare Advantage than Original Medicare.

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Medicare Advantage Plans Coverage For Some Services And Procedures May Require Doctors Referral And Plan Authorizations

Medicare Advantage plans try to prevent the misuse or overuse of health care through various means. This might include prior authorization for hospital stays, home health care, medical equipment, and certain complicated procedures. Medicare Advantage plans often also require your primary care doctors referral to see specialists before they will pay for services.

Why Should I Choose Medicare Advantage

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Medicare Advantage covers some of the gaps of Original Medicare and usually offers a $0 premium through a private company. It can be an affordable option for patients who are not currently sick or in need of intense medical care. If a patient’s situation worsens, it might be difficult or expensive to switch plans.

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A Doctors Experience With Medicare Advantage Plans

In 2012, Dr. Brent Schillinger, former president of the Palm Beach County Medical Society Services Foundation pointed out a host of potential problems he encountered with Medicare Advantage plans as a physician. Heres how he describes them:

  • Care can actually end up costing more, to the patient and the federal budget, than it would under original Medicare, particularly if one suffers from a very serious medical problem.
  • Some private plans are not financially stable and may suddenly cease coverage. This happened in Florida in 2014 when a popular MA plan called Physicians United Plan was declared insolvent, and people were called by doctors who canceled their appointments.
  • One may have difficulty getting emergency or urgent care due to rationing.
  • The plans only cover certain doctors, often drop providers without cause, breaking the continuity of care.
  • Members have to follow plan rules to get covered care.
  • There are always restrictions when choosing doctors, hospitals, and other providers, which is another form of rationing that keeps profits up for the insurance company but may limit patient choice.
  • It can be difficult to get care away from home.
  • The extra benefits offered can turn out to be less than promised.
  • may ration certain high-cost medications.

What Do Medicare Advantage Plans Cover

We just went through the top reason people dont like Medicare Advantage, but do the pros and cons match with what the private health plans are designed to provide?

Medicare Advantage plans combine Original Medicare coverage into a private health plan and often offer extra benefits. The Medicare Part C program allows plans to offer the following benefits to its plan members:

  • hospitalization
  • Special Needs Plans .
  • Medical Savings Account .

The different types of all-in-one Medicare coverage help serve different needs. Not all plan types are available in all areas. PPO plans, for example, allow members to get care out of their provider network, but members pay more when they do. SNP plans help people who are institutionalized, have a chronic illness, or have special financial needs. In comparison, Original Medicare is a one-size-fits-all system.

Read Also: Do I Need Medicare If I Have Tricare

Is Medicare Advantage Better Than Original Medicare

There is not one universal right or wrong answer when it comes to choosing Original Medicare vs. Medicare Advantage.

If you want the freedom to travel and seek health care from any doctor or provider who accepts Medicare, and if you want the opportunity for more predictable health care spending with the help of a Medigap plan, Original Medicare may be the right choice for you.

If you want to enjoy extra benefits such as dental, vision and drug coverage under one easy plan that also covers your hospital and medical benefits, if you want added protection against potentially high surprise medical bills, or if you want a plan that can offer customized coverage for a specific health condition, then a Medicare Advantage plan may better suit your needs.

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If you have a Medicare Advantage or Medicare Part D prescription drug plan, you will likely have a card for that plan that also contains a beneficiary identification number.

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Original Medicare Vs Medicare Advantage: How Private Insurance Company Plans Work

Medicare Advantage plans are provided by private health insurance companies and group healthcare providers whereas Original Medicare coverage comes from the federal governments Medicare program. Both have their strengths and weaknesses.

The reason private plans seem to be so inexpensive, compared to a regular HMO or PPO health plans is that the federal Medicare programMedicare is a federal health insurance program for people ages 65 and older and people with certain disabilities…. pays the plan you choose for your care.

When you join a private health plan, Medicare pays the plan $750 per month or more to take over your hospital and medical care costs . Add to that your monthly Part B premium , plus any additional monthly premium the plan charges, and youll get an idea of the true cost.

An important thing to understand about a Medicare Advantage plan is that, while enrolled, you no longer have your Original Medicare benefits. The insurance company behind your plan provides your benefits and makes up its own rules. They must follow Medicares guidelines, but those guidelines are very broad and leave a lot of room for interpretation. This often leads to a good deal of frustration about whats covered, what isnt covered, how much youll pay out of pocket, and getting prior approval for coverage.

Find Medicare Advantage Plans Available In Your Area

Your best bet is to give us a call. Were a great resource for helping you find the right Medicare Advantage Plan.

We have MA agents in 38 states who can sell plans from most major carriers. Contact Medicare Plan Finder to discuss your Medicare options.

There is never any obligation to buy, and all of the information is free. You can also give us a call at 1-855-783-1189 .

Recommended Reading: Who Is Eligible For Medicare Extra Help

Can I Enroll In A Medigap Plan Later If I Enroll In A Medicare Advantage Plan Now

If you enroll in an Advantage plan now, you may leave the plan and switch to Medigap later. However, youll have to wait until either the Annual Enrollment Period or the Medicare Advantage Open Enrollment Period to make changes.

Its important to know that most beneficiaries will only get a one-time Medigap Open Enrollment Period. This is your only opportunity to enroll in a Medigap plan without answering health questions.

If you miss this one-time opportunity to enroll, and you choose to enroll in a Medicare Advantage plan instead, you will have to answer the health questions, go through medical underwriting, and the carrier could deny your application due to pre-existing conditions.

The Real Disadvantage Of Medicare Advantage Plans

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In Understanding Medicare in 4 Easy Steps, we outline how to determine if Medicare Advantage or Original Medicare and a Medigap plan is the best option for you. To paraphrase, we suggest that theres a single fundamental difference that helps most people make the right choice. Thats because the extra benefits offered by Medicare Advantage plans take a back seat to this one issue.

The difference is this. With Original Medicare and supplemental Medicare insurance, you pay the bulk of your major medical costs upfront through monthly insurance premiums. Doing so lets you budget your health care costs.

When you have Medicare Advantage, you pay most of your health care costs when you use services. For this reason, it is very difficult to budget your health care costs. And this is one of the primary disadvantages of Medicare Advantage plans. If you fit into one of the five categories above, this wont be much of an issue. If not, it could put you in a world of hurt.

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Can Medicare Advantage Plans Be Free

Some MA plans are labeled as free because they offer $0 premiums to be enrolled in the plan. This can be an attractive alternative for those people looking to save money.

Theres generally no difference in coverage between a free plan and a paid plan because regardless of cost, most MA plans offer parts A and B, prescription drugs, and other additional coverage.

Some companies are able to offer $0 premium plans because when they contract with Medicare, they are given a set amount of money to cover Part A and Part B insurance. If a company can save enough money elsewhere then it may be able to pass along savings to members, up to and including $0 premium plans.

Heres the catch.

While you may pay no premiums in some cases, you will still probably have to pay deductibles, copayments and coinsurance. Also different plans will offer different costs based on their structures. For example, PPO plans charge different copayment amounts based on whether your provider is in-network or out-of-network.

And dont forget, even if you get a $0 premium MA policy, youre still responsible for paying your Part B premium every month.

You can find Medicare Part C plans with a $0 premium in your area by talking with a Medicare Plan Finder agent or by using Medicares Find a 2020 Medicare plan tool.

Can I Use My Current Providers If I Switch To Medicare Advantage

As noted above, a Medicare Advantage HMO plan requires you to use a specific network. If your healthcare provider is part of that network, no problem. If not, you may be liable for the full cost of treatment for out-of-network care.

Other plans donât prevent you from using out-of-network providers. However, you may have to pay more for care if they donât accept your planâs payment schedule.

Keep in mind that plans may change their list of in-network providers at any time, or a provider might leave on their own.

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The Pros And Cons Of Medicare Advantage

These popular plans may carry hidden risks. Heres what to know.

If youre one of the 63 million Americans enrolled in Medicare, youre probably being deluged by marketing pitches for Medicare Advantage plans, which offer managed care with low or zero premiums.

Medicares fall open enrollment season starts Oct. 15 and runs through Dec. 7, when you can switch your coverage between Original Medicare and Medicare Advantage, change Medicare Advantage plans, or make changes to your prescription drug plan.

All that marketing seems to be working. Recently, 42 percent of Medicare beneficiaries were enrolled in Advantage plans, up from 31 percent in 2016, according to data from the Kaiser Family Foundation. Those numbers include 50 percent of Black and 54 percent of Hispanic enrollees vs. 36 percent of whites in 2018. By 2025, half of Americans are expected to be in Advantage plans.

Its easy to see the appeal of Advantage. Original Medicare doesnt cover all your medical expenses, while Advantage plans have cost-sharing requirements but then cap your out-of-pocket costs. Plus, you have low premiums and the simplicity of all-in-one coverage.

But there can be hidden risks to Advantage plans, especially for those with major health issues.

Some people in Medicare Advantage end up paying unexpectedly high costs when they become ill or find their network lacks the providers they need, says Tricia Neuman, senior vice president at Kaiser.

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