Medicare Advantage isn’t necessarily bad. However there are some good reasons why some people do not like it.
Have you been considering Medicare Advantage? If you asked at your doctors office or at the local hospital you may have been told that Medicare Advantage is not as good as original Medicare. Perhaps you may have even heard this from friends too.
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This is why it is so important to have someone in your corner when you are making these decisions.
A Medicare Advantage plan is a type of Medicare health insurance plan that gives you an enhanced range of benefits beyond what Original Medicare covers.
The Provider
Care providers may not like Medicare Advantage as much because they don’t appreciate the burden of extra paperwork that sometimes comes with referrals and prior authorizations required by Medicare Advantage. They also have to ensure the doctors they refer you to are in network and covered.
The Patient
For the patient, Medicare Advantage can be a good thing, if they fully understand how it works. Many people don’t like Medicare Advantage because it isn’t what they thought it would be.
A Medicare insurance broker can help you understand all of your healthcare plan options. The best part is, it doesn’t cost you anything. You can get all of the professional insight and advice that you need to make the best decision.
Some Reasons Why People Don’t Like Medicare Advantage
Medicare Advantage plans are not bad. They just get a bad rap sometimes.
All too often, people try to enroll in a Medicare Advantage plan on their own without the free help from a Medicare insurance broker like LMA Insurance.
When they do this, they miss some really important details. Then they are later unhappy with the plan, but it’s not the fault of the plan—it’s simply that they didn’t know the rules before they enrolled.
There are still Copays
One of the biggest selling points of Medicare Advantage is that the premiums are very low, often $0. However, this doesn mean that there are not any copays or out of pocket costs at all.
Many are sold believing they are just getting “extra” benefits with no out of pocket costs.
With Medicare Advantage, you may end up paying a copay for your “regular” doctor visit that is $0 to $20. This doesn’t sound too bad if you only need a check up once or twice per year.
However, if you need to see a specialist you will often also have to pay an additional copay of $10-40. Plus, there can be copays for any blood work or other diagnostic testing you might need done (x-rays, ect.). In a worst case scenario, if you need chemotherapy or dialysis you could end up paying hundreds of dollars in copays, up to your annual maximum out-of-pocket.
The good news is these copays will almost always be less than original Medicare.
It is very important to make sure that you read all of the fine print and understand all of the details of any plan that you are considering. Your agent should give you a Summary of Benefits for the plan you are considering so you can be sure of everything.
Medicare Advantage is NOT FREE
In the overselling of low to zero dollar premiums, many people are mistakenly led to believe that Medicare Advantage makes their Medicare free.
This simply is not true.
Medicare Advantage plans do often have a $0 premium, but that does not mean that they are free. This is done to make the plans more attractive so that the insurance company can sell them to more people.
When you choose Medicare Advantage, you must still continue to pay for your Part B coverage. You will pay for Part B coverage for the entire time that you have Medicare Advantage.
Medicare Advantage has its own Network of Doctors and Hospitals
When you have original Medicare, you can go anywhere in the country that accepts Medicare and your medical services will be covered by your chosen plan. However, that is not how Medicare Advantage works.
Medicare Advantage Plans have their own networks of doctors, hospitals and other healthcare service providers. Only providers within the network will be covered. If you go outside the network, then you will have to pay full price for the bill out of your own pocket.
Be sure to ask your doctors and other care providers if they are part of the Medicare Advantage plan network that you are considering. If not, you may be better off opting for original Medicare or a Medicare Supplement plan. Original Medicare and Medicare Supplements give you access to hundreds of thousands of doctors, hospitals and specialists, nationwide. The only drawback to these options is a higher out of pocket cost (Original Medicare) or a higher monthly cost (Medicare Supplement).
Sadly, many people are unable to get the care they need from the doctors that they know and trust just because they failed to check and see if their doctors were in the network. This can be prevented by working with an agent who can confirm what plans and networks all of your doctors accept.
Specialists Require Referrals
Many Medicare Advantage plans are HMO style networks. In this case, you will have to have a special referral from your primary doctor in order to be allowed to see a specialist. If this sounds unfair or like a headache to you, make sure that you shy away from plans with HMOs.
Medicare Advantage Plans Change Every Year
Medicare Advantage Plans can change every year. This is perfectly normal and to be expected. Each year they make small adjustments to their benefits and networks to be more competitive. You know that each year, you will receive your Annual Notice of Change letter from your plan.
The Annual Notice of Change letter informs you of the changes that will be made to:
- Provider Networks
- Pharmacy Networks
- Plan Premiums
- Plan Copays
- Deductibles
- Coinsurance
- Ancillary Benefits (limited services such as vision and dental)
This is important to understand, because if you choose a plan for a specific benefit, you will want to make sure that benefit is still offered each year. If you are unhappy with the changes the plan makes, you will be allowed to switch to a different Advantage Plan. However, you can only do this during the fall Medicare Annual Election Period. If you enrolled with an agent, we recommend that you meet or contact them, during this time, to review the changes and see if any affect you for the following year.
If you do not want to or are not able to commit to sitting down and doing thorough research about your healthcare coverage each fall, you should consider a Medigap plan instead, because those plans rarely change if ever.
There is an out of Pocket Maximum
An out of pocket maximum is designed to protect you from paying more than a certain amount out of your own pocket for healthcare services when you are on a Medicare Advantage plan. In 2022 the maximum that amount can be is $7,550. It is often lower, but you should know how much it is to determine if you can afford it in catastrophic medical situations (multiple hospitalizations, chemotherapy, dialysis).
It can help make your decision much easier, because you probably already know whether or not you have the fund to pay out over the next year for copays and services.
Also consider that if the timing works against you, that could mean paying some very large bills in just a matter of a few months. For example, if Susan needs dialysis starting in September, she may pay out the out-of-pocket maximum. However, that will reset at the start of the year. If Susan continues to need dialysis in the new year, she will have to pay out that out of pocket maximum again.
So with an expensive, albeit necessary treatment like dialysis or chemotherapy, a patient could end up paying both years of the out of pocket maximum within a matter of six months. This is a much different scenario than paying it over a 24 month time period. If your finances can’t weather this you should consider original Medicare and a Medigap plan instead.
Prior Authorizations are Needed for Many Services
Like all businesses, insurance companies have to make a profit. One way that they keep their costs down is by scrutinizing services and procedures to make sure that they are not paying for things that are frivolous, unnecessary. For many services beyond very basic needs, your doctor’s office will have to check with your plan to make sure that the service will be covered.
Don’t assume that this is a mere formality. It is not. Services and medications are denied everyday. An example is instead of a knee surgery they may ask you to do physical therapy first to see if that improves things first.
Not Sure Which Plan Is Best For You? Ask Your Local Medicare Agent
If you find yourself overwhelmed or unsure which plan is best for you, reach out to a local Medicare insurance broker. They can help you, free of charge, to find which plan will work best for you.
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