Medicare Advantage Plans promise low costs and extra benefits, but are they right for you? This article examines the downsides of Medicare Advantage and things to consider before joining a plan.
With over 28 million enrollees as of 2022, Medicare Advantage Plans have become an extremely popular alternative to Original Medicare. However, Medicare Advantage Plans have some significant drawbacks that are important to understand before signing up. Keep reading to learn the potential disadvantages and get the full picture on Medicare Advantage.
What is Medicare Advantage?
Medicare Advantage, also known as Medicare Part C, allows private insurance companies to provide Medicare benefits. These plans must cover everything Original Medicare does, but can do so with different costs and rules.
Many Medicare Advantage Plans offer extra benefits not included in Original Medicare, such as vision, dental, hearing aids, and gym memberships. Most plans also include Part D prescription drug coverage. Monthly premiums tend to be lower than Medigap and Part D Plans.
However, restrictions and less flexibility for seeing providers you choose are the tradeoff for these extra benefits. Let’s look closer at the negatives when you enroll in Medicare Advantage.
Disadvantages of Medicare Advantage Plans
While Medicare Advantage Plans can save money in premiums, they have some significant downsides:
Restricted Provider Network
You can only go to doctors and hospitals in the plan’s network, except in emergencies. With Original Medicare, you can see any provider that accepts Medicare. This network restriction can mean changing doctors or having to drive farther for care. Do your research to ensure your providers are in-network before joining a Medicare Advantage Plan.
Prior Authorization Requirements
Many Medicare Advantage Plans require you to get prior authorization before receiving certain services. This means delays in accessing care while waiting for approval. Under Original Medicare, you don’t need approval to see providers or receive services if they are covered benefits.
Limited Coverage Outside Plan Area
Medicare Advantage Plans typically only cover emergency and urgent care outside the plan’s service area. With Original Medicare, your coverage goes with you anywhere in the U.S. This makes travel more difficult with Medicare Advantage.
Medicare Advantage Plans may deny coverage for services they consider not medically necessary. You can appeal denials, but the process can be lengthy. Under Original Medicare, coverage decisions are made by Medicare, not a private insurer.
Drug Formulary Restrictions
If the Medicare Advantage Plan includes prescription drug coverage, it can only cover certain medications on a formulary. Your prescription may have high copays or not be covered at all. With a Part D Plan, you can switch plans each year if the formulary changes.
Medicare Advantage Plans can increase premiums each year up to certain limits set by Medicare. Your costs may go up unexpectedly. Under Original Medicare, Part B premium increases apply to all beneficiaries equally.
Annual Disenrollment Periods
You can only leave a Medicare Advantage Plan or switch to Original Medicare during certain times of year. This means you could be stuck in a plan you no longer like until January 1.
Pros of Sticking with Original Medicare
Given the disadvantages of Medicare Advantage Plans, you may want to consider staying with Original Medicare and adding a Medigap Plan instead. Here are some of the pros of Original Medicare plus a Medicare Supplement:
- Freedom to see any doctor or hospital accepting Medicare nationwide
- Predictable costs from year to year
- Less prior authorization requirements
- Travel coverage throughout the U.S.
- No networks or out-of-network costs
- Choice of any Medigap Plan with benefits meeting your needs
- Guaranteed renewable Medigap coverage
Yes, Medigap Plans have higher premiums than Medicare Advantage. But the flexibility and predictability is worth it for many Medicare beneficiaries. Weigh the pros and cons of each path to make the best choice.
Questions to Ask About Medicare Advantage
If you are considering a Medicare Advantage Plan, be sure to ask these important questions:
- Are my doctors and hospitals in network?
- Does the plan require referrals or prior authorization?
- What is covered if I need care outside the plan’s service area?
- What are the costs and rules for prescription drug coverage?
- What extra benefits such as dental or vision are included?
- What is the monthly premium in addition to the Part B premium?
- What is the annual out-of-pocket maximum for Part A and B services?
- Can I easily switch back to Original Medicare if needed?
Get all the details in writing before making a decision. Medicare Advantage marketing materials don’t always tell the full story.
Why Doctors May Not Accept Medicare Advantage
Many physicians limit the number of Medicare Advantage Plans they contract with or refuse them entirely. There are a few reasons why:
- Low reimbursement rates from Medicare Advantage Plans
- Hassle of getting prior authorizations from multiple plans
- Plans dropping providers mid-year from networks
- Delayed payments and administrative burdens
If keeping your doctor is imperative, talk to their office to learn which plans they accept before choosing a Medicare Advantage Plan.
Should You Join a Medicare Advantage Plan?
Medicare Advantage works well for some beneficiaries, but also has some big disadvantages. Think carefully about your situation:
- Do you travel frequently or live part of the year out-of-state? Original Medicare will have nationwide coverage.
- Do you have complex medical conditions with specialists in different health systems? You’ll have more provider choice under Original Medicare.
- Do you take expensive prescription drugs? A Part D prescription drug plan may offer better coverage than a Medicare Advantage drug formulary.
- Is having dental, vision and other extra benefits important? Most Medigap Plans do not include these.
- Is keeping premiums and out-of-pocket costs as low as possible crucial? Medicare Advantage Plans can provide savings for some.
Make sure you understand how Medicare Advantage Plan rules will impact your healthcare access and costs before making a decision. While they seem appealing at first glance, the disadvantages may outweigh the benefits for your situation.
- Medicare Advantage Plans have restricted provider networks, unlike Original Medicare where you can see any provider.
- Prior authorizations may be required before getting care with a Medicare Advantage Plan.
- Medicare Advantage Plan coverage is limited outside the plan’s service area, except for emergencies.
- Medicare Advantage Plans can deny coverage for services they consider not medically necessary.
- Drug formularies and high copays may limit prescription coverage under Medicare Advantage.
- Premiums and benefits can change each year with Medicare Advantage Plans.
- You can only switch out of Medicare Advantage and back to Original Medicare at certain times of the year.
- Doctors often do not accept Medicare Advantage due to low reimbursement rates and administrative hassles.
- Evaluate your personal situation carefully when choosing between Medicare Advantage and Original Medicare.
While joining a Medicare Advantage Plan seems attractive initially, understand the potential restrictions and limitations first. For many beneficiaries, Original Medicare paired with a Medigap Plan is the better option to provide flexibility and predictable costs.
We’re Here to Help
You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Manatee Insurance Solutions a Call at (352) 221-3779. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.
Why do some people not like Medicare Advantage?
Some people may not like Medicare Advantage for various reasons. Some common reasons include limited provider networks, restrictions on seeing specialists, higher out-of-pocket costs, and the potential for frequent changes in plan coverage.
What is the difference between Medicare Advantage and a Medicare Supplement Plan?
Medicare Advantage (also known as Medicare Part C) is an all-in-one alternative to Original Medicare, offered by private insurance companies. It includes Medicare Part A (hospital insurance) and Part B (medical insurance) coverage, and often includes prescription drug coverage as well. On the other hand, a Medicare Supplement Plan (also known as Medigap) works alongside Original Medicare and helps cover the out-of-pocket costs that Medicare does not pay for.
How do I enroll in a Medicare Advantage Plan?
To enroll in a Medicare Advantage Plan, you must be eligible for Medicare Part A and Part B. You can generally enroll during the Initial Enrollment Period when you first become eligible for Medicare, or during the Annual Enrollment Period that occurs each year from October 15th to December 7th. You may also be eligible to enroll in a Medicare Advantage Plan during a Special Enrollment Period if you meet certain criteria.
Are Medicare Advantage Plans bad?
Medicare Advantage Plans are not inherently bad, but they may not be the right fit for everyone. Like any health insurance plan, there are pros and cons to consider. Some people may find that Medicare Advantage Plans offer more comprehensive coverage and additional benefits, while others may prefer the flexibility and freedom of choice that comes with Original Medicare and a Medicare Supplement Plan.
What are the pros and cons of Medicare?
The pros of Medicare include access to a wide network of doctors and hospitals, guaranteed coverage for certain services, and the ability to enroll in additional coverage options such as Medicare Advantage or a Medicare Supplement Plan. The cons of Medicare include potential gaps in coverage, cost-sharing responsibilities, and certain limitations on coverage for specific services.
Why do some doctors not like Medicare Advantage?
Some doctors may choose not to accept Medicare Advantage Plans due to various reasons. One reason is that Medicare Advantage Plans often have different payment structures and reimbursement rates compared to traditional Medicare. Additionally, some doctors may feel that the restrictions on referrals and specialist visits in Medicare Advantage Plans limit their ability to provide optimal care for their patients.
How do I switch back to Original Medicare from a Medicare Advantage Plan?
If you are currently enrolled in a Medicare Advantage Plan and wish to switch back to Original Medicare, you can do so during the Medicare Advantage Disenrollment Period, which occurs from January 1st to February 14th each year. During this period, you can disenroll from your Medicare Advantage Plan and return to Original Medicare. You may also have the option to enroll in a Medicare Supplement Plan to help cover the out-of-pocket costs of Original Medicare.
Can I still get Medicare if I have a Medicare Advantage Plan?
Yes, if you have a Medicare Advantage Plan, you still have Medicare Plan. Medicare Advantage Plans (Part C) are private insurance plans that provide an alternative way to receive your Medicare Part A and Part B benefits. However, it’s important to understand the coverage and limitations of your specific Medicare Advantage Plan.
What are the cons of Medicare Advantage Plans?
While Medicare Advantage Plans offer certain benefits, there are cons to consider as well. Some common cons of Medicare Advantage Plans include limited provider networks, restrictions on out-of-network care, potential for higher out-of-pocket costs, requirements for prior authorization, and the potential for changes in plan coverage from year to year.
Are there many Medicare Advantage Plans to choose from?
The availability of Medicare Advantage Plans may vary depending on the area where you live. In some areas, there may be a wide range of plans in your area to choose from when you sign up for Medicare, while in other areas, the options may be more limited. It’s important to research and compare the Medicare Advantage Plans available in your area to find the one that best suits your healthcare needs and budget.