Medicare Advantage Plans: The Pros And Cons 

Is your 65^th birthday approaching quicker than you’d like? You know you’ve got some decisions to make about Medicare and it’s time you understood what your options are and fortunately, you do have some options. You probably know that Original Medicare is available but you’ve likely heard that it has some gaps in coverage that could leave you paying a lot out-of-pocket. You’ve also probably seen a lot of advertising about Medicare Supplement insurance but you’re confused about coverage because almost a dozen different plans are available to you.

You’ve likely heard about Medicare Advantage plans and how in some areas of the country you don’t even have to pay an additional premium and that certainly sounds good as well. But you may also know that with any insurance product, there are pros and cons and that’s what we will address here but first things first. Let’s discuss Medicare Advantage Plans pros and cons.

What’s the Difference between Medicare and Medicare Advantage?

Original Medicare is designed to cover your inpatient hospital expenses with Part A and then also cover your outpatient medical expenses (doctors and diagnostic testing) with Part B. Most people refer to it as Original Medicare because it was initially formed and passed into law back in 1965. Later, the government realized that seniors needed coverage for prescription drugs and added Part D.

Shortly afterward, private insurance companies began offering Medicare Supplement insurance (Medigap) and Medicare Advantage plans (Part C) to fill in the coverage gaps in the Original Medicare program. There we gaps in coverage, there were deductibles, and there was coinsurance. All of these contributed to out-of-pocket expenses that for many seniors, were difficult to plan for and afford.

What is Medicare Advantage (Part C)

Medicare Advantage plans are provided by private insurance companies and provide all the coverages found in Original Medicare (including Part D), and additional coverages and benefits not found in Original Medicare or even Medicare Supplement insurance. Some plans will even provide additional solutions like dental, hearing, and vision coverage. It’s important to note, however, you are stilled required to pay your Part B premium no matter which plan you select.

Advantages of a Medicare Advantage Plan

As with any type of health insurance, there are advantages and disadvantages depending on your specific needs. Here are some of the advantages to having a Medicare Advantage plan:

• Lower Insurance Cost – Although you must continue to pay your Part B premium along with your Medicare Advantage premium, in some areas of the country there is no premium required by the Medicare Advantage insurance company. Medicare Advantage plans also establish an out-of-pocket limit for medical expenses that you’ll have to pay for each year. Once you have reached your plan’s limit, your cost for covered medical services will be zero for the remainder of the year.
• Medicare Advantage Plans are Similar to Group Health Insurance – If you are leaving an employer who provided health insurance for employees, the Medicare Advantage plan will appear very similar to your health insurance through work because deductibles, coinsurance, drug coverage, and doctor networks are all part of a Medicare Advantage plan.
• It’s a Single System – With a Medicare Advantage plan, the enrollee only deals with their Medicare Advantage insurance company instead of Original Medicare, a Medicare Supplement company, and their Part D insurance carrier. This means you carry one card instead of three.
• Better Coordination of Services – Since most Medicare Advantage plans use an HMO network where you choose a Primary Care Physician, this physician is like the quarterback on your health care team. Your Primary Care Physician (PCP) communicates with other physicians (usually specialists) providing your healthcare to make certain that everyone is on the same page when it comes to treating your medical needs.
• Additional Benefits – While Medicare Advantage Plans cover the same services found in Medicare Part A and B, most plans also offer prescription drug, dental, hearing, and vision coverage as part of their plan.

Disadvantages of Medicare Advantage Plans

• Prior Approval – Many seniors prefer to be their own quarterback when it comes to health care services and dislike having an insurance company telling them what they need and don’t need. With HMO networks the goal is to manage medical care costs and therefore the insurance company will likely require prior approval before agreeing to pay for medical services such as elective surgeries, home health care services, and unusual medical devices. Typically, if your PCP believes that a product or service is needed, the insurance company will give approval.
• Payment Due prior to Services – You are likely to have copays for doctors and specialist visits that will have to be paid when you arrive at the office. If you are being seen by multiple doctors or specialists, this could lead to substantial upfront costs for doctor visits and diagnostic testing.
• Diminished choice of Providers – When you join a Medicare Advantage HMO, there will be a limited list of providers to choose from since not every doctor will agree to join an HMO. If your choice is to see a provider outside of the HMO, you can expect to pay significant out-of-pocket expenses to do so.

You Can Change if you’re not Satisfied

Changing from one Medicare Advantage insurer to another is not difficult and can be done during the annual Open Enrollment Period. In fact, it makes good sense to shop your coverage each year if you are not satisfied with your insurance company for any reason. If, however, you decide to change from a Medicare Advantage plan to Medicare Supplement insurance, if you do not make the change within the first year of your enrollment into Medicare Advantage, you will likely not have guaranteed issue underwriting with a Medicare Supplement insurer. Of course, if you are very healthy, this would be a moot point but if you have health issues, this could result in a higher rate because of the medical underwriting.