REMINDER: Medicare Advantage Is NOT the Same Thing as Traditional Medicare

I recently got a call from one of my girlfriends, who said she was having difficulty with helping her beloved aunt at home.

Her aunt had been experiencing altered mental status, and she was falling a lot. So I thought, “Okay, great. Let’s send her to the hospital where I’m on staff, and then, afterwards, we can transfer her and get her spiffed up at the rehab unit.”

Seems like a good idea, right? No, wrong.

My friend discovered what many Americans have been finding out after the fact—that her aunt had signed her Medicare over to Medicare Advantage, which is a type of health insurance offered to Medicare beneficiaries by private insurance companies.

When you have Medicare Advantage, you can’t go to any doctor and you can’t go to any facility of your choice.

While it may seem like a more comprehensive and cost-effective option, it is important to understand the disadvantages of Medicare Advantage as well. So let’s discuss the disadvantages, from the perspective of a doctor.

What is Medicare Advantage?

Medicare Advantage, also known as Medicare Part C, is a type of health insurance offered by private insurance companies to Medicare beneficiaries. It covers all the benefits of the original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance), as well as additional benefits such as dental, vision and hearing services. Medicare Advantage plans also have an out-of-pocket maximum, which is the most you will pay in a year for covered services.

Medicare Advantage plans are required to offer at least the same benefits as the original Medicare, but they may also have different rules, costs and restrictions.

While Medicare Advantage plans may seem like a more comprehensive and cost-effective option, they also have several disadvantages. Let’s discuss them in detail:

Limited provider networks

One of the main disadvantages of Medicare Advantage plans is that they often have limited provider networks. This means that you may be restricted to seeing certain doctors or going to certain hospitals. If you have a doctor or hospital that you prefer, make sure they are in the plan’s network before enrolling.

Increased out-of-pocket costs

Medicare Advantage plans may also have higher out-of-pocket costs than Medicare. This can include deductibles, copayments and coinsurance. Additionally, some Medicare Advantage plans may require you to pay a premium on top of your Part B premium.

Prior authorization requirements

Medicare Advantage plans may require prior authorization for certain medical services or procedures. This means that you may need to get approval from the plan before receiving the service. This can delay or limit your access to care.

Plan changes and disruptions in care

Medicare Advantage plans may change their benefits or provider networks from year to year. This can disrupt your care and require you to find new doctors or hospitals. Additionally, if you move to a different area, your plan may no longer be available.

Limited coverage for travel

If you travel frequently, Medicare Advantage plans may not provide coverage outside of their service area. This can be a problem if you need medical care while traveling.

Prescription drug restrictions

Medicare Advantage plans may also have restrictions on prescription drug coverage. They may limit which drugs are covered or require you to use certain pharmacies.

Confusing plan options

There are many different Medicare Advantage plans available, each with its own rules and benefits. It can be confusing to compare plans and choose the one that is best for you.

Financial incentives for insurance companies

Finally, let’s be clear about something: Medicare Advantage plans provide financial incentives for insurance companies to limit your care or deny coverage. What does this look like at the doctor’s office? The plans often restrict care by imposing prior authorization on patients, limiting what healthcare providers and patients can see on their records and limiting when patients can see a doctor. This can lead to decreased quality of care and can put your health at risk.

Comparing Medicare Advantage to traditional Medicare

It’s important to compare Medicare Advantage to Original Medicare before making a decision. Original Medicare allows you to see any doctor or hospital that accepts Medicare, and there are no restrictions on referrals or prior authorizations. However, Original Medicare does not cover certain services such as dental, vision and hearing. You may also need to purchase a separate prescription drug plan.

Medicare Advantage plans may provide additional benefits, but they also come with the disadvantages listed above. You should carefully consider your health needs and preferences before choosing a plan.

Conclusion

Medicare Advantage may seem like a comprehensive and cost-effective option for Medicare beneficiaries, but it also has several disadvantages. These include limited provider networks, increased out-of-pocket costs, prior authorization requirements, difficulty obtaining referrals to specialists, plan changes and disruptions in care, limited coverage for travel, prescription drug restrictions, confusing plan options, and financial incentives for insurance companies.

Before choosing a plan, it’s important to compare Medicare Advantage to traditional Medicare and carefully consider your health needs and preferences.

FAQs

Q: Can I switch from Medicare Advantage to traditional Medicare?
A: Yes, you can switch from Medicare Advantage to Original Medicare during certain times of the year. But, in my experience, returning to Original Medicare can be challenging, especially for Medicare patients who are elderly, disabled and vulnerable.

Q: Are all doctors and hospitals covered by Medicare Advantage plans?
A: No, Medicare Advantage plans often have limited provider networks.

Q: Are there financial penalties for switching from Medicare Advantage to traditional Medicare?
A: No, there are no financial penalties for switching from Medicare Advantage to Original Medicare. However, there is no dollar amount attributed to the inconvenience, which often means potential emotional and health consequences for patients.