Should I Switch to Medicare Advantage?

Medicare Advantage plans are a popularly advertised, one-stop shop for services not offered by Traditional Medicare, such as Part D (drug coverage) and some dental, vision, and hearing services. However, Medicare plans are constantly changing. New research shows concerning trends in Medicare Advantage overcharges, fraud, and billing abuse. 

Open enrollment for Medicare Advantage plans begins from January 1st to March 31st, 2023. Whether you are browsing plans for yourself or a loved one, this article provides you with the latest information on the Medicare market to choose the best health coverage this enrollment season. 

Medicare Advantage and Medicare Comparison

First, compare the following coverage options in both plans to determine which best suits your health needs. 

Medicare Advantage vs. Original Medicare

Sources: Center for Medicare & Medicaid Services, Forbes Health

Original Medicare and Medicare Advantage Pros & Cons

Now that you better understand the services available in Original Medicare versus Medicare Advantage plans, let’s examine the pros and cons.

Medicare Advantage Pros:

Access

The one-stop shop for Medicare Advantage plans makes for an attractive, simplistic option for receiving the care you need. Medicare Advantage plans typically include your drug plan and don’t require a separate supplemental policy as traditional Medicare beneficiaries do. 

MA plans also help you avoid running out of covered hospital days, helping mitigate costly expenses in the long run. 

Personalized Plan Structure

Medicare Advantage offers different plan types to help you identify your situation best. For instance, if you have a chronic health condition, SNP Advantage plans can be of assistance in reducing your medical costs. 

We asked a United Health Agent why seniors should work with an agent to consider MA plans over Traditional Medicare. They stated, “Medicare Advantage Plans are a great option compared to Traditional Medicare plans because they act as a stand-alone plan that includes your prescription drug plan and premium costs. Health agents can help navigate plan choices and upgrades seamlessly, where Traditional Medicare has a fixed offer of benefits”. 

Cost

Many MA plans charge low or no monthly premiums and cap out-of-pocket expenses. For instance, in-network expenses are capped at $8,300 (excluding drugs) for 2023, or $12,450, depending on if your plan allows you to use out-of-network providers.

Medicare Advantage Cons:

Limited Service Providers 

Generally, you can only utilize services from doctors who are in the plan’s network. This limits your choice of providers and facilities you can visit, especially if you choose one of the more popular MA plan types, such as an HMO. MA costs depend on how much care you need, making it difficult to budget health care costs.

With many options to choose from in Medicare Advantage plans, be aware of additional costs advertisements may push you to consider. Often, these plans can be costly and heavily marketed. “How many times do I have to tell these telemarketers that I don't need help picking out my Medicare Advantage plan? And they're so smug, like, "Oh, I'm young, I can read a script." And they offer you grocery cards and then say, "Oh, you don't qualify." -@DeniForestek, Nov 25, 2022. 

Prior Authorization Approval

Unlike traditional Medicare, you may need referrals for specialist visits in MA plans. Some insurers require “prior authorization” for many procedures, drugs, or facilities. This can result in high out-of-pocket costs or the risk of forgoing treatment due to differences in care recommendations. 

If you are denied care due to plan restrictions, you can file for an appeal to get it reversed. Appeals are reversed 75% of the time, but only about 1% of beneficiaries/providers file appeals. It’s essential to know the rights and protections Medicare systems have in place to serve your healthcare needs best.

Travel Limitations

Generally, medical care outside of the U.S. isn't covered. Some plans offer supplemental benefits that cover emergency and urgently needed services when traveling. However, this can cause issues if you travel often. Check your plan's coverage options to see if additional benefits are available for travel.

Original Medicare Pros:

No Networks

Original Medicare has no limitations on the providers, hospitals, and clinics you can visit to receive care. 

No Prior Authorization Required

Traditional Medicare beneficiaries avoid the delays and stresses of needing prior authorizations for procedures, drugs, and facilities.

Original Medicare Cons:

No Cap on Out-of-Pocket Expenses

The 20% copay required by traditional Medicare can add up quickly in hospitalization, testing, and procedure expenses. Because of this, many people purchase a supplemental insurance plan such as Medigap. You may also qualify for supplementary coverage through an employer or Medicaid to help cover costs. 

Medigap policies can be costly, averaging $150 to $200 monthly. 

Does Not Include Drug Coverage

The biggest downside to traditional Medicare is that it doesn’t include drug coverage. You must purchase a separate Part D plan for coverage. In 2023, the estimated average monthly premium for Medicare Part D stand-alone drug plans is $43 based on data from the Kaiser Family Foundation. 

The $35 cap for a month’s supply of insulin for part D enrolees will also begin in 2023 under provisions included in the Inflation Reduction Act.