Is Medicare Advantage Bad? It Might Be if You’re Not Healthy

The Medicare Advantage Plan serves as an all-in-one alternative to the original Medicare. These are offered by private insurance companies that contract with the federal government with the promise that they provide insurance benefits to all who enrolled in the plan. Medicare Advantage Plans can also be called Medicare Part C. It is a type of Medicare health plan provided by a private insurance company.  

This year, the Centers for Medicare and Medicaid Services (CMS) will be implementing a new set of benefits for Medicare Advantage. These are the benefits that used to be unavailable in the traditional Medicare. It is expected that many plans will be offering these benefits this year, according to PBS news hour. However, this Medicare Advantage is not without its disadvantages, although it also has a lot of advantages. If you want to know more about these, read further.  


The Different Types of Medicare Advantage Plans


The costs for treatment-related services, preventive and diagnostic services may also be covered by Medicare Advantage. Medicare Advantage Plans come in different types such as Preferred Provider Organization (PPO), Special Needs Plans (SNP), Medical Savings Account (MSA), Private Fee-for-Service (PFFS) and the Health Maintenance Organization (HMO). Remember that not all Medicare Advantage Plans are created equal. Each of it has its different set of restrictions, along with benefits and rules. Most plans provide coverage for prescription drugs. Other plans still require a referral if the patient needs to see a specialist for his medical condition. There are providers that cover a portion of the patient’s out-of-network care. But, there are also Medicare Advantage providers that only pay for doctors and facilities that are within the PPO or HMO’s network.  

Each Medicare Advantage plan will have its own Summary of Benefits that the agent must give right away to those who wish to enroll. This is why the people behind highly recommend that one must review or peruse this document. This is to avoid ending up getting surprised with the amount of out-of-pocket costs that you will be paying down the road.


Medicare Advantage Accepts All Medicare-Eligible Individuals  


Providers of Medicare Advantage should not refuse any Medicare-eligible enrollees. Those who have been diagnosed with an illness may find that medical care costs soar if they are under Medicare Advantage Plan due to out-of-pocket expenses and co-pays. If you find yourself paying more for out-of-pocket expenses, you can always switch back   to the original Medicare once every year during the enrollment period.  

The truth is that Medicare Advantage plans are not offering the same options that Medicare plus Medigap provides. Most plans in Medicare Advantage require individuals to turn to their network of health providers and doctors. But, since Medicare Advantage are also mandated to accept any Medicare-eligible participant and that they are not allowed to choose whom to accept, they structure their co-pays and deductibles in a way that discourages those who are diagnosed with an illness.  


Primary Care Doctors Should Be In Your Medicare Advantage Plan Network


Those who plan to sign up must see to it that their primary care doctors are in their Medicare Advantage Plan network. The list of doctors included in the list of this network do change from time to time, so it is best to check if your primary care doctor is included. If your preferred doctor decides to drop, you become at risk of paying a hefty share of the cost. In such cases, there is also a huge tendency that you will be required to pay for the full cost and won’t expect anymore for a reimbursement.  


Return to Original Medicare if You’re Diagnosed with a Serious Illness


At first glance, Medicare Advantage Plans or Medicare Part C may seem as if it has several significant advantages. It combines the benefits that one may obtain from Medicare Parts A, B and D. In fact, some Medicare Advantage Plans offer it with zero dollar premiums only to find that most insurers offering such plan may only have you paying for a hefty out-of-pocket costs and may only select you as their customer if you’re healthy.  

Consider putting an end to your Medicare Advantage Plan if you have been diagnosed with a serious illness. Then, go back to your Original Medicare so you can still be covered no matter which doctor and hospital you choose, for as long as they’re participating in the Medicare Program. With Original Medicare, you can choose to see any doctor in any hospital whenever you want to be treated or receive medical attention. You may find yourself paying more when you choose the Original Medicare, but being able to access more doctors and hospitals is more important now that you have a serious illness. It will now become easier for you to find a specialist and find hospitals that offer treatment for your type of illness. Although with original Medicare you will be paying a greater amount for Medigap supplemental coverage, Part D drug coverage and Part B doctor coverage.  


Always Check Medicare Website for Coverage on Drugs


The list of drugs that are approved for Medicare Advantage Plans always change. Plans may change or delete some drugs in the list.   Changes to the deductibles and copayments for the medications prescribed to you also often occur so check the Medicare website always before making decisions.  


Medicare Advantage Plan Have the Discretion as to What and When to Cover


Most Medicare Advantage Plans provide several coverages such as hospital coverage that includes hospital visits, home health care, hospice care and stays in the nursing facility. Unfortunately, since there aren’t any established criteria that determines exactly what constitutes medical necessity, the insurers in Medicare Advantage Plan have a very flexible discretion when it comes to choosing what they will cover and when they would stop providing coverage. In turn, some elderly individuals who are under a skilled nursing care can be easily turned down when requesting for coverage just by decreeing such type of care as custodial. This is one of the reasons why only three percent of these Medicare Advantage Plans have been rated as “excellent” by the federal government. On the other hand, there are also only 35 percent of these Medicare Advantage Plans receive a four star rating, which is deemed as “above average”.  


The Disadvantages of Medicare Advantage


One of the disadvantages of Medicare Advantage is that patients may find it difficult to get emergency or urgent care because of rationing. Some plans only allow coverage for certain doctors and some just drop their coverage without a clear cause. In turn, continuity of patient care will also be halted. The restrictions set regarding doctors and hospitals to opt for is a method of rationing that means more profit for the insurance company yet could mean very limited choice for patients.  

There are also Medicare Plan providers that promise extra benefits, but in the end they only cover far less than what they’ve promised. Those that promise coverage for Part D prescription drugs are also more likely to ration pricey medications.  


Some Medicare Advantage Plans Only Provide Local or Regional Coverage


With Medicare Advantage most of its plans can either be local or regional only which means access to healthcare providers can only be limited only up to a thousand options. For patients who choose to seek treatment away from their home, they are bound to have difficulty finding coverage.  

Individuals who are residents in more than one state and would choose to live in another state to seek treatment or find shelter from the freezing cold of winter, may not be able to find coverage for some   of their medical or treatment needs. This is when a traditional Medicare plus Medigap becomes a better option. The same thing can also be said of individuals who frequently travel. Medigap plans provide coverage in all 50 states while Medicare Advantage does not.  


Some Plans May Suddenly Stop Coverage


Medicare Advantage Plans may subject patients to a host of issues since care can actually entail higher costs not just for the patients, but the federal budget as well, compared to the costs that they may pay if they’re under original Medicare.   However, some private plans do not have complete financial stability thus they may suddenly decide to stop coverage. Back in 2014, Physicians United Plan, which is a popular Medicare Advantage plan in Florida, was declared insolvent. In turn, doctors also decided to cancel appointments.  


Are all Medicare Advantage Plans Bad?


Unfortunately, most of these Medicare Advantage plans are misunderstood. Oftentimes, people decide to enroll without even knowing first the complete benefits and risks that come with signing up for a plan. As a consequence, many of them miss those important details and end up being unhappy and regretting that they signed up for the plan. So, it is a must that one should know the rules and restrictions before enrolling. The fine print could be too fine, it can be daunting to read, but it is best to go through the hassle of reading every detail to become aware of everything about the plan.  


Zero Premium Plans Lead People to Believe the Plan is Free


These Medicare Advantage plans are being paid by Medicare itself. Once you sign up for the plan, Medicare will then pay the insurance company to ensure they will take on your health risk. In turn, the insurance company will also charge you for anything that they want, as stipulated on the rules and restrictions of the plan.  

A lot of Medicare Advantage plans offer very low or even zero premiums. This is part of their marketing strategy to attract people to enroll in their plan so that their company will also be able to receive payment from Medicare. Unfortunately, this zero premium is also making many beneficiaries confused. Most of them mistakenly believe that they do not have to pay for Part B doctor coverage. However, the truth is, you will still be paying for Part B all throughout the time that you are enrolled in the plan.  

Those who signed up for Original Medicare and Medigap plan will have access to about a million providers all throughout the country.  


Original Medicare vs. Medicare Advantage


When you sign up in a traditional Medicare like Plan F, you will be paying a higher premium up front. But, you will be paying a small amount for out-of-pocket expenses. There will be no more copays for hospital, lab work and doctor visits. On the other hand, Medicare Advantage plan only asks for a lower premium. As a result, individuals still need to shell out some of their own money for copays. They also need to pay for coinsurance for services that they use. For example, those who signed up for Medicare Advantage may have to pay an amount of $10 or $20 whenever they see a primary care physician. They may also find themselves paying for $50 or less each time they see a specialist. Moreover, your doctor will also be asking you to obtain some lab work somewhere where you will be required to spend money for copay. If you need to undergo MRI and other laboratory tests, prepare yourself to spend an extra $100 or $200 for copays.  


You Only Have to Deal with One Entity if You Opt for Medicare Advantage  


Most Medicare Advantage Plans offer your insurance needs to only one insurance company.   Just think of the hassles that you have to go through when filing a separate set of documents from a private insurer for your Part D coverage, a government-appointed contractor for your original Medicare and for a private Medigap insurer. But, with Medicare Advantage you will only be dealing with a single entity so too many paper works would be one less thing to worry about.  


The Need to Perform Due Diligence Every Year


Those who signed up for Medicare Advantage plan are encouraged to do their due diligence every year. This is to ensure that you will always be updated with the latest changes or additions to your plan. Most Medicare Advantage plans make frequent changes to their provider network, deductibles, copays, coinsurances and pharmacy network.  

Those who are still planning to sign up for Medicare Advantage Plan must carefully consider first all aspects of it. In other words, remember that the devil is usually in the details, so read the fine print thoroughly before finally affixing your signature.  



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Written by HealthStatus Crew
Medical Writer & Editor

HealthStatus teams with authors from organizations to share interesting ideas, products and new health information to our readers.

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