Is Medicare Advantage Plan a Good Option: Pros and Cons

For those becoming eligible for Medicare, one of the biggest decisions is whether to enroll in Original Medicare or a Medicare Advantage Plan. Medicare Advantage is an alternate option to traditional Medicare that is offered by private insurance companies. There are good reasons to consider a Medicare Advantage Plan, but also drawbacks to weigh. This article explores the pros and cons of Medicare Advantage Plans to help you make an informed enrollment decision.

What is a Medicare Advantage Plan?

Definition of Medicare Advantage Plan

Medicare Advantage, also known as Medicare Part C, provides an alternate way to receive your Medicare benefits. These plans are offered by private insurers that have been approved by Medicare. Medicare Advantage Plans provide at minimum the same coverage as Original Medicare Part A and Part B. Many plans also include prescription drug coverage and other benefits not offered by traditional Medicare.

Comparison to Original Medicare

The key difference between Medicare Advantage and Original Medicare is that Advantage Plans are managed by private insurers while traditional Medicare is administered directly by the federal government. Medicare Advantage Plans often have more benefits but narrower provider networks. Original Medicare offers wider provider choice but requires supplemental plans to fill coverage gaps.

Pros of Medicare Advantage Plans

Comprehensive Coverage

Medicare Advantage Plans combine medical, hospital and usually prescription drug coverage all under one plan. This can be more convenient and straightforward than juggling multiple plans with Original Medicare. Many Advantage Plans also include dental, vision, hearing and wellness benefits not covered by traditional Medicare.

Additional Benefits

Many Medicare Advantage Plans offer appealing extra benefits traditional Medicare does not cover. These can include gym memberships, transportation to medical appointments, over-the-counter medication allowances, home healthcare, and more. The extra benefits provided vary by insurer and plan.

Managed Care

Medicare Advantage Plans feature managed care with copays for services rather than the deductibles and coinsurance of Original Medicare. The copay structure can make healthcare costs more predictable. Many Advantage Plans have copays for doctor visits, hospital stays and prescription drugs with an annual out-of-pocket maximum.

Cons of Medicare Advantage Plans

Network Restrictions

A disadvantage of Medicare Advantage Plans is that they have provider networks, so your choice of doctors and hospitals is limited. Out-of-network care is generally not covered except in emergencies. Original Medicare offers flexibility to see nearly any provider nationwide who accepts Medicare.

Potential Out-of-Pocket Costs

While copays in an Advantage Plan can be predictable, the copay amounts can still be costly depending on the services received. Hospital copays of several hundred dollars per day are common. Plus you still pay the Part B premium just as with Original Medicare. Supplemental Medigag Plans are not available to fill gaps in Medicare Advantage.

Limitations on Specialists

Some Medicare Advantage Plans require referrals to see specialists. Others may limit access to certain types of specialist care. Under Original Medicare you can self-refer to any specialist accepting Medicare without plan restrictions or approval delays.

Disadvantages of Medicare Advantage Plans

Limited Provider Options

Medicare Advantage Plans have provider networks that are typically smaller than providers accepting Original Medicare nationwide. So your access to doctors and hospitals is limited to just the plan’s network except for emergencies. Also, provider networks can change from one year to the next with insurers.

Potential Plan Changes

Insurers can discontinue Medicare Advantage Plans from one year to the next or reduce plan benefits. Your costs, copays, provider network and included benefits with a Medicare Advantage Plan could change annually at the insurer’s discretion within Medicare guidelines.

Restricted Coverage for Travelers

A Medicare Advantage Plan covers only limited emergency and urgent care when traveling outside the plan’s service area. Original Medicare provides coverage nationwide for all Medicare-covered services. So Advantage Plans provide less flexibility for snowbirds or frequent travelers.

Medicare Advantage vs. Original Medicare

Differences in Cost-sharing

Original Medicare has deductibles, coinsurance and copays for covered services. Medicare Advantage features copays only for services. But Medicare Advantage copays can still be expensive for things like hospitalization. Supplemental Medigag Plans help fill gaps in Original Medicare but can’t be used with Medicare Advantage.

Access to Prescription Drugs

Most Medicare Advantage Plans include Part D prescription drug coverage. To get drug coverage with Original Medicare, you need to purchase a separate Part D prescription plan. Both offer comparable drug coverage, but Advantage combines medical and drug benefits.

Flexibility in Provider Choice

Original Medicare allows you to see any healthcare provider nationwide that accepts Medicare. Medicare Advantage Plans have more limited provider networks. But Advantage Plans typically offer benefits like dental coverage that Original Medicare does not provide.

Enrolling in a Medicare Advantage Plan

Eligibility Criteria

To join a Medicare Advantage Plan you must be enrolled in Medicare Part A and Part B. You must live in the plan’s service area and cannot have End-Stage Renal Disease at time of enrollment. Medigap policies cannot be used to pay costs in an Advantage Plan.

Enrollment Periods

You can enroll in a Medicare Advantage Plan when first eligible for Medicare, during the annual election period from October 15th to December 7th, or during Medicare Advantage open enrollment from January 1st to March 31st. There are also special enrollment periods for certain circumstances.

Considerations Before Enrollment

Before selecting a Medicare Advantage Plan, review provider networks, prescription formularies, total out-of-pocket costs and benefits closely. Understand how the plan coordinates with other insurance you have. Enrolling in Medicare Advantage is making a 12-month commitment to the plan.

Considering Switching Back to Original Medicare

Reasons to Switch

Common reasons people switch from a Medicare Advantage Plan back to Original Medicare include high out-of-pocket costs, plan benefit cuts, limited provider access and lack of specialist approvals. A change in health conditions or medications can also prompt a return to Original Medicare.

How to Switch

You can leave a Medicare Advantage Plan and return to Original Medicare during the annual election period or Medicare Advantage open enrollment. In certain circumstances you may qualify for a special enrollment period. Your plan can advise if a special enrollment situation applies to you.

Understanding the Implications

If you switch from Medicare Advantage to Original Medicare, you may need to buy separate Part D drug coverage and a Medigap policy. Pre-existing condition waiting periods and underwriting may apply for Medigag Plans. Carefully consider these implications before leaving Medicare Advantage.

Additional Information about Medicare and Medicare Advantage Plans

Medicare Supplement Plans

Medigag Plans help pay costs not covered by Original Medicare like copays and deductibles. But Medigap policies cannot be used to pay costs in Medicare Advantage Plans. Medigag Plans only work with Original Medicare.

Prescription Drug Coverage (Part D)

If you join a Medicare Advantage Plan that does not include drug coverage, you can purchase a standalone Part D prescription plan. You cannot be enrolled in both a Medicare Advantage Plan and a separate Part D Plan at the same time.

Resources for More Information

Consult official Medicare resources like Medicare.gov and USA.gov/Medicare for more details on Medicare Advantage Plans vs. Original Medicare. You can also discuss options with a licensed Medicare insurance broker in your state.

Conclusion

In summary, Medicare Advantage Plans offer benefits like capped out-of-pocket costs, comprehensive coverage, and extra benefits not provided by Original Medicare. But Medicare Advantage also imposes provider network restrictions and less flexibility. Review the pros and cons carefully before making your Medicare enrollment decision.

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 Senior Health Advocates a Call at (386) 222-3030. 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.

FAQS

Is a Medicare Advantage Plan a good option?

 The decision of whether a Medicare Advantage Plan is a good option depends on your individual needs and preferences. These plans offer additional benefits and may have lower out-of-pocket costs compared to traditional Medicare, but they also have specific network restrictions.

What are the pros and cons of Medicare Advantage?

 The pros of Medicare Advantage include additional benefits like prescription drug coverage, vision, and dental services. These plans may also have lower out-of-pocket costs. However, the cons include potential network restrictions, limited provider options, and the need to follow specific rules and regulations of the plan.

What is the difference between a Medicare Advantage Plan and a Medicare Supplement?

 A Medicare Advantage Plan is an alternative to traditional Medicare, while a Medicare Supplement (also known as Medigap) is a supplemental insurance plan that helps cover the costs not covered by Original Medicare. Medicare Advantage Plans often include prescription drug coverage, while Medigag Plans do not.

Can I have a Medicare Advantage Plan and a Medicare drug plan?

 No, you cannot have both a Medicare Advantage Plan and a separate Medicare drug plan. Medicare Advantage Plans may include prescription drug coverage, so if you have an Advantage Plan, you do not need a separate drug plan.

Can I join a Medicare Advantage Plan at any time?

 No, you can only join or switch Medicare Advantage Plans during certain enrollment periods. The Annual Enrollment Period, from October 15th to December 7th, is the main time to make changes to your Medicare Advantage coverage.

What is the Medicare Part B premium?

 The Medicare Part B premium is the monthly premium you pay for medical coverage under Medicare Part B. This premium is separate from any premium you pay for a Medicare Advantage Plan.

Do Medicare Advantage Plans also cover prescription drugs?

 Yes, many Medicare Advantage Plans include prescription drug coverage. These plans are known as Medicare Advantage Prescription Drug (MAPD) plans.

What are the benefits that Original Medicare covers that Medicare Advantage Plans may offer?

 Original Medicare covers hospital (Part A) and medical (Part B) insurance. Medicare Advantage Plans may offer these benefits, along with additional benefits such as prescription drugs, vision, dental, and hearing coverage.

Can I switch from Original Medicare to a Medicare Advantage Plan?

 Yes, you can switch from Original Medicare to a Medicare Advantage Plan. However, it is important to carefully review different plans and consider your healthcare needs before making the switch.

Where can I find information about Medicare Advantage Plans?

 You can find information about Medicare Advantage Plans on the official Medicare website or by contacting your state health insurance assistance program. The Medicare Plan Finder tool is also a helpful resource to compare different plans and their coverage options.