ORIGINAL MEDICARE
You may have heard someone tell you Medicare Advantage Plans are bad. However, there are benefits when you make the most suitable selection.
Not all plans are equal.
Those enrolling themselves into Medicare Advantage may not realize an out of network doctor, a drug that doesn’t have coverage or a fine-print stipulation requirement.
I know if my plan didn’t cover my doctor or my medications like I thought it would, I would consider it to be the worst Medicare Advantage plan.
Although, when using an agent to enroll in a Medicare Advantage plan, verifying doctors and understanding all the information is more convenient. I know why people think Medicare Advantage Plans are inferior; it’s because the Medicare Advantage plan they select is wrong for them.
Today we are going over who benefits from Medicare Advantage and why some people think the plan is the worse policy out there.
At the end of this, you’ll be able to decide for yourself!
So, Are Medicare Advantage Plans Good
Any agent will tell you that some coverage is always better than no coverage. Someone that can’t afford Medigap should consider Medicare Advantage.
Also, someone that isn’t eligible for Medigap could find financial protection from Medicare Advantage; while it won’t be substantial, it’s better than nothing.
Let’s say Stacy has Medicare; well, she ends up with a cancer diagnosis that costs her deductibles and 20% of all bills with no limit on her costs.
Now, with Part C, Stacy would have a Maximum Out of Pocket between about $5,000- $10,000 depending on her policy and service area. The Maximum Out of Pocket is a cap on how much you can spend in one calendar year on services the plan covers.
There are plenty of reasons people select Medicare Advantage policies, including low upfront costs and the feeling of an all in one Medicare plan.
While seemingly sweet on the surface, there are pros and cons to almost everything; so, keep reading to understand better.
Always remember, the choice is yours.
What is Wrong With Medicare Advantage Plans
We know Stacy could pay way more than $10,000 for chemotherapy or radiation with ONLY Medicare. However, if her doctor isn’t in the Medicare Advantage network, costs are 100% her responsibility.
Outside the network, the plan AND Medicare WON’T PAY!
Staying in-network isn’t the only nuisance beneficiaries encounter. Having a copayment to see the primary doctor for a referral and then a copayment for the specialist is another typical grievance.
Further, some services require prior authorization. However, once you understand the requirements, it’s easier to navigate your policy.
If Lucy knows seeing her primary care doctor is necessary before seeing her specialist, there is transparency, and she can adjust to the rules.
But, when Lucy goes straight to the specialist only to discover she needs to pay 100% of the costs, she’s going to tell everyone Medicare Advantage plans are inadequate.
The Misunderstandings of Medicare Advantage plans give them a bad reputation.
Misunderstanding these plans is easy though, they change every year during the Annual Enrollment Period.
So, just when you think you got the hang of understanding your coverage, it’s no longer the same policy. These changes can be inconvenient for many, especially those with a long list of doctors and drugs.
In some cases, Medicare Advantage is just wrong for a person. Some people feel overwhelmed by the perpetual copayments and plan limitations; those feelings are all legitimate.
A person with many doctors could find the copayments more challenging than a single monthly premium. Although many people are happy with a Medicare Advantage policy, it’s just a matter of understanding what you’re buying AND when you need to pay.
When you expect to have coverage go a certain way, and it doesn’t, disappointments arise. But, working with an agent can eliminate these surprises.
Why Are Medicare Advantage Plans so Cheap
Medicare pays the advantage plan company to handle your claims, so these companies make money. You must continue to pay the Part B premium.
Also, these plans keep costs down by charging you for the services you obtain. The costs can add up quickly when you need lots of care.
When Lucy takes an ambulance to the hospital, and the doctor in charge orders inpatient care, Lucy could have serious fees.
For example, the ambulance copayment, which runs around $150-$400 depending on where you live, and then the hospital can cost $400 or more each day for days 1-6. Although this is an example, in some service areas, Medicare Advantage plans have lower or higher costs.
If the inability to predict costs scares you, Medicare Supplement coverage could be more suitable.
A good rule of thumb, when the premium is higher, the out of pocket costs are lower. Also, a lower premium policy likely has higher out of pocket costs.
For example, if Lucy has Medigap Plan G when the above incident occurs, her only out of pocket costs would be her Part B deductible for the ambulance. However, Lucy pays the Plan G premium every month, even when she doesn’t go to the doctor.
Do You Want to Pay Now or Pay Later
Medigap coverage is excellent for those that want predictability, freedom to see any doctor, and the benefits of no referrals.
Medicare Advantage is beneficial for healthy people that don’t mind paying for services as they go because they have adequate savings in case of a healthcare catastrophe.
Although those that don’t qualify for Medigap or can’t afford supplement insurance could benefit from Medicare Advantage, only because some coverage is better than no coverage.
Are Medicare Advantage Plans Worth It
Medicare Advantage plans are certainly worth the zero dollar premium; however, it’s your choice to decide if the coverage is right for you.
Coverage changes from county to county, so if you travel, this plan might be more of a hassle. However, many seniors find going to the doctor is difficult; so, traveling far is out of the question.
For beneficiaries that have difficulties leaving home, Medicare Advantage doctors in certain areas will start providing telehealth services. Virtual health visits keep patients safe, in-home while meeting with a doctor over a tablet or computer.
You must check with the plan to see how they cover these services; not all policies provide this benefit.
Most Medicare Advantage plans cover Part D, routine dental, vision, and occasionally audiologist care. Some policies provide comprehensive dental for an extra amount; however, extensive coverage isn’t available with all plans.
The vision coverage rarely has frills; generally, you get the exam and maybe $100 toward glasses. Of course, there is always an exception.
Some people live in areas where Medicare Advantage plans cover an abundance of services; for example, 71% of those in Puerto Rico have Medicare Advantage coverage. The Humana Gold Plus HMO in San Juan includes telehealth, fitness, transportation, home safety device, and home modification coverage.
Of course, with a Health Maintenance Organization, you MUST double check the doctor is in the network or risk paying the full costs. Now, that same Humana plan in Texas is different; maybe that’s why only 36% of beneficiaries selected Medicare Advantage in Texas?
The worth of a Medicare Advantage plan depends on your location, healthcare needs, budget, and preferences. Some healthy people live in prime Medicare Advantage areas, and they prefer to pay as they go; these feelings are justifiable.
Worse Medicare Advantage Plans
The worse plan for you depends on your needs. Those with a grocery list of doctors may find an HMO policy is a nightmare; however, someone with one doctor could overpay on a PPO policy.The worse plan for you is the plan you don’t analyze. When it comes to Medicare Advantage there are many different ways you could find yourself in disappointment.
It could be the endless copayments, the necessary referrals, or the small network of doctors. Either way, doing your research on the policy of interest should be a top priority.
If reading through details of insurance coverage is confusing, call one of our agents and they can help identify the best policy for you.
Common Questions and Answers
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About The Author
Our employer-sponsored retiree health insurance is planning on a possible change to a UHC Medicare Advantage PPO from a regular UHC PPO. We are in discussions. What would be some of the questions and issues we should address before voting?
Hi Holly! This question is difficult to answer without knowing more information about what type of employer coverage you have with the UHC PPO plan currently. UHC PPO may or may not work similarly to a UHC Medicare Advantage PPO. I recently updated our FAQ article on Medicare Advantage vs. Medicare Supplements that should help guide you on what questions to address before voting. For example, I would be asking questions like “what copays can you expect to pay out of pocket when you visit your providers now vs. Medicare Advantage PPO”, “what providers are in your current network vs. the Medicare Advantage PPO”, “what is the out-of-pocket maximum spend limit currently compared to the Medicare Advantage PPO”, etc. I would think the questions would be similar to the same questions you would ask when comparing Medigap with Medicare Advantage. I hope this helps!
I have a niece that I have became her guardian through the courts . She has disability due from mental retardation from birth. Her father worked and kept her on his Insurance with his job. Now her Father got cancer in 2012 loss his job his home and filed for Medicare for his daughter then, how ever part D was not a law to have then as he continue to fight for his life while he took care of his daughter and 4 young grandsons they never made them selves guardians of their daughter as they did not know they needed to nor did he understand he ever needed to get a part D coverage for her she is 40 yrs now and he has passed a way . I am now playing catch up trying to get her a supplement plan or advantage plan to go with her Medicare . Now they are telling me she will have a Life time late enrollment penalty . Really she is like a 3 or 4 yr old who needs lots of daily help and her dad fought for his life every day he could. She isn’t 65 yrs she is healthy and takes no medicine at now . I am trying to do my best but this means she will pay a pentacle from 2015 to 2019 1% a month .this seems unfair since she could not help her self and her father was fighting every day for his life. Is this really true or is there any thing I can do to avoid this penalty for her .
Hi June. I’m so sorry about your current situation regarding your niece. Unfortunately yes, she will have a penalty for the rest of her life. If her income is low and she qualifies for Medicaid or Extra Help, her penalty would be waived. You could sign her up for a Medicare Advantage Plan that covers prescription medications and only have to pay the penalty she has incurred over the last four years. The 2020 Part D premium is $32.7, so if she went that route she would only have to pay somewhere around $16 per month. ($32.74 x .48 {4 years} = $15.71) The sooner you sign her up, the better. That way she will stop increasing her penalty and it will stay where it’s currently at. If she were to get a supplement plan & pick up Part D now, the monthly premium would be around $48.50. ($32.74 + $15.71 = $48.45) I would recommend looking into getting her Extra Help to see if she can get her penalty waived. I hope this helps!
My husband is 79 and underwent chemo/radiation in 2018; cancer is now gone. however he is undergoing speech and swallowing therapy. We have a medicare advantage thru humana. Everytime there is a procedure or scans, xray we pay a co-pay of $325 or 220 or 180. Amaximum out of pocket of $10,000 for medical and meds together. Is there a better plan? he also has afib and kidney disease and copd. I have the same plan as him, my ailments are not as devastating but I do have a few. Suggestions?
Hi Ruthie! Unfortunately, your husband would not be approved for a Medigap plan. I would recommend two things in your situation. First, work with an agent during each AEP, which is right now, to find a lower cost advantage HMO if possible or PPO with all doctors in-network so his maximum out of pocket costs are lower. Second, since you’re a little healthier, you may be eligible for a Medigap plan. That would lower the total out of pocket costs between both of you.
What would you suggest for a 59 year old female with malignant ascites, I have ssdi and they are putting me on medicare but no information on what my options are. I live in Washington state.
Hi Peggy! Unfortunately, not all states require carriers to offer Medigap plans to those on disability. Washington is one of those states that don’t require it, but some carriers may still offer it. However, the monthly premiums are usually higher for those on disability when compared to those that aged into Medicare.
What most beneficiaries do in your situation is they enroll in a Medicare Advantage plan until they turn 65. Once they turn 65, those on disability will get another Open Enrollment Period that allows them to sign up for a Medigap plan. During this six-month window, you cannot be turned down due to your disability or charged higher premiums.