Picking Medicare after 65 can be tricky. They sound pretty good initially, sometimes with extras like dental and vision combined with regular Medicare at a low monthly fee.

But wait, these plans might not cover everything, especially when you get sick. This can leave you with unexpected bills.

Surprisingly, over half of eligible Medicare beneficiaries have chosen a Medicare Advantage plan. So, why do people say MA plans are bad?

Let's find out the answers in detail!

The Basics Of Medicare Advantage Plan

Coming across Medicare Advantage Plans is common. They're a popular choice, but knowing the basics is important before enrolling.

What is a Medicare Advantage Plan?

An MA Plan is an alternative way to get your Medicare Part A (hospital insurance) and Part B (medical insurance) coverage.

Instead of receiving benefits directly from Medicare, you can enroll in a private health insurance company approved by Medicare.

This company provides all your Part A and B benefits and often includes Part D (prescription drug coverage) as well.

Types of MA Plans:

There are different types of MA Plans, each with its own set of rules:

HMO (Health Maintenance Organization):

You need a referral from your primary care physician (PCP) to see any specialists within the plan's network. This network may be limited, so choice of doctors could be restricted.

PPO (Preferred Provider Organization):

You can see any doctor in the plan's network without a referral, but seeing in-network doctors typically comes with lower costs.

Out-of-network care is usually covered, but with higher costs and potentially needing prior authorization from the plan.

MDS (Medical Savings Account Plan):

These plans combine an HMO or PPO structure with a savings account. You contribute money to the account to pay for certain healthcare costs, and the plan may contribute as well.

Original Medicare vs. Medicare Advantage Plans: A Side-by-Side Comparison

Before we dive deep into the pitfalls of Medicare Advantage Plan, have a look at the comparison between original Medicare and MA plan:

Feature	Original Medicare (Parts A & B)	Medicare Advantage Plan (MA Plan)
Type of Coverage	Fee-for-service	Managed care provided by private insurance companies approved by Medicare
Parts Covered	Usually Parts A & B (hospital & medical insurance). May require separate Part D plan (prescription drug coverage)	Combines Parts A & B, often includes Part D, and may offer additional benefits
Network	Broad network of doctors and hospitals that accept Medicare	Limited network of doctors and hospitals contracted with the specific MA Plan
Doctor Choice	See any doctor or specialist who accepts Medicare	Usually requires a referral from a primary care physician (PCP) within the plan's network to see specialists (except HMO with Point-of-Service option)
Monthly Rate	Part A: Usually no premium Part B: $174.70 per month (subject to income adjustments). Part D: Varies depending on the plan.	May have lower monthly premiums, but often have deductibles, copays, and out-of-pocket maximums
Cost Coverage	Covers about 80% of your Medicare-approved expenses. Deductibles, copays, and coinsurance levels are set by the government.	Plans typically cover a set percentage of costs after you meet the deductible. May involve higher out-of-pocket expenses depending on your healthcare use.
Prior Authorization	Not required	May require approval from the MA Plan before covering certain treatments or medications
Extra Benefits	Typically none	May offer vision, dental, hearing coverage, gym memberships, or wellness programs
Enrollment Changes	Can switch between Original Medicare and MA Plans during specific enrollment periods	More restrictions on switching plans throughout the year

Why Medicare Advantage Plans Are Bad: A Closer Look

While Medicare Advantage Plans (MA Plans) offer a tempting package of benefits and sometimes lower premiums, they aren't perfect for everyone.

Here's a deeper dive into the potential drawbacks of MA Plans:

Limited Choice of Doctors and Hospitals (Network Restrictions)

Under Original Medicare, you have the freedom to visit any doctor who accepts Medicare, covering about 90% nationwide. But, MA plans operate within specific provider networks.

The Trade-off:

Medicare Advantage Plans (MA Plans) often come with a trade-off: a limited network of healthcare providers.

This can be a significant drawback if you have a preferred physician outside the network or require frequent specialist care.

Potential Consequences:

• Difficulty finding a new in-network doctor, especially specialists.
• Disruption in ongoing care with your current doctor if they are not in the network.
• Limited options for out-of-state care while traveling.

It mostly impacts people with complex medical conditions who need to see specialists regularly, those who value a good relationship with a specific doctor, or individuals who travel frequently.

Hidden Costs and Prior Authorization

While Medicare Advantage Plans (MA Plans) often boast lower premiums, a closer look reveals there can be more to the story. And the prior authorization hinders instant access to care.

Beyond the Premiums:

Although many Medicare Advantage (MA) plans advertise zero monthly premiums, it's important to note that you still need to pay your Part B premium if you're enrolled in one.

Most people with MA plans (which is almost 73% of the total enrollees in 2023) don't pay extra monthly premiums,

But they often have out-of-pocket expenses like deductibles, copays, and maximums, which can accumulate, particularly for those needing frequent medical services.

Prior Authorization Hurdles:

Getting approval in advance for medical care can cause delays or even prevent necessary treatment.

While original Medicare has limited prior authorization, Medicare Advantage (MA) plans use it much more extensively.

In 2021, MA plans fully or partially denied 2 million prior authorization requests, about 6% of the 35.2 million reviewed.

Only 11% of these denials were appealed, but 82% of those appeals were partially or fully overturned, indicating patients won when contested.

Despite successful appeals, care still faced delays.

This issue mainly affects those with chronic conditions needing regular treatment, people expecting frequent medical care, or those worried about possible delays in treatment.

Marketing and Enrollment Challenges

The advertisements of Medicare Advantage plans may seem appealing to you, but their marketing tactics and enrollment issues pose a different scenario.

Confusing Information Overload:

Seniors are bombarded with TV ads, mailers, and phone calls promoting MA Plans. The ads talk about good stuff but don't say everything, like network limits or costs.

They don't fully explain limitations like network restrictions or out-of-pocket costs. It's hard to know which plan is best with all this info.

Hidden Agendas and Misleading Sales Tactics:

Some marketing practices prioritize sales over accurate information. High-pressure tactics might focus on low monthly premiums without mentioning potential hidden costs or limitations.

Many people don't understand $0 premiums with Medicare Advantage plans. They're not actually free, despite sounding like it.

While these plans often have low or no premiums, enrollees still have to pay their Part B premium. According to CMS, the projected average monthly premium is $18.50 in 2024.

But the monthly premium cost was $17.86 in 2023. All that misleads seniors into enrolling in a plan that doesn't suit their needs.

Enrollment Complexity:

Enrolling in MA plans can be complicated. There are many factors to consider, like network details and potential costs.

Understanding these requires careful research and analysis. Seniors may struggle to navigate this complex decision-making process alone.

Additional Concerns

1. Quality of Care:

Some studies suggest that quality of care can vary among MA Plans. It's important to research individual plans and their track record for patient satisfaction.

2. Plan Changes and Network Fluctuations:

MA Plan networks and benefits can change from year to year. You may be forced to switch doctors or plans if your current options no longer meet your needs.

Keep in mind: MA Plans can be a good option for you, particularly if you are healthy and prioritize lower monthly premiums.

But if you have many medical needs, prefer more doctor choices, or worry about extra costs, go for the Original Medicare with a Medigap plan.

Stuck in a Bad Medicare Advantage Plan? Here's How to Get Out

Disappointed with your current Medicare Advantage Plan (MA Plan)? Don't worry, you have options! Here's how to navigate the situation:

Assess the Situation:

Identify what's making your plan a bad fit. Are there limited network providers, unexpected out-of-pocket costs, or frustrating prior authorization processes?

Utilize Open Enrollment Period:

During the Medicare Open Enrollment Period (October 15 - December 7), you can switch to a different MA Plan or even return to Original Medicare.

Consider plans with broader networks, lower out-of-pocket costs, or features more aligned with your needs.

Seek Guidance:

State Health Insurance Assistance Programs (SHIP) offer free, one-on-one counseling to help you compare plans and choose the best option for your situation.

Consider a Medigap Supplement Plan:

If you choose Original Medicare, consider a Medigap supplement plan to help cover out-of-pocket costs like deductibles and copays.

Remember: Switching plans might require some research and paperwork. Take time to find a plan that truly meets your needs can save you money and ensure you get the healthcare you deserve.

3 Steps To Pick the Best Medicare Advantage Plan for You

If Medicare Advantage is your top choice, ensure you follow the necessary steps to select the most suitable plan for your needs.

Skipping these steps often leads to ending up with a subpar Medicare Advantage plan. Here are the tips to pick the best Medicare Advantage plan for you:

1. Take Note of Your Needs: Self-Assessment is Key

Before diving into plan comparisons, take a moment to reflect on your current and future healthcare needs. Here are some questions to consider:

• Do you have any chronic medical conditions that require ongoing care?
• How often do you typically see a doctor?
• Do you have a preferred primary care physician (PCP) or specialists you want to continue seeing?
• Do you anticipate needing out-of-state healthcare services while traveling?
• What are your budget limitations for monthly premiums and out-of-pocket costs?
• Are there any extra benefits, like vision or dental coverage, that are important to you?

2. Compare Your Options: Research Makes a Difference

Once you know what you need, it's time to check out your Medicare Advantage choices. Here's where to find helpful resources:

• Medicare Plan Finder: Visit the official Medicare website (https://www.medicare.gov/plan-compare/) to search for MA Plans using your ZIP code. Filter your search by plan type, drug coverage, and benefits.
• State Health Insurance Assistance Programs (SHIP): These government-funded programs offer personalized counseling to help you compare plans and make informed decisions. Locate your local SHIP program at https://www.shiphelp.org/.
• Insurance Company Websites: Individual insurance companies offering MA Plans will have detailed information about their plans on their websites.

Review these resources to get a better understanding of specific benefits, network details, and costs associated with each plan.

3. Check Plan Details Before Enrolling: Don't Get Caught Off Guard

Once you've identified a few promising MA Plans, take a closer look at the fine print before enrolling. Consider these details:

• Provider Network: Check if your preferred doctors and hospitals are covered, and if there's a broad network available for flexibility.
• Costs: Understand monthly premiums, deductibles, copays, and out-of-pocket maximums to assess affordability.
• Prior Authorization: Be aware of any requirements for approval before certain treatments, which can cause delays.
• Additional Benefits: Evaluate if extras like vision or dental coverage align with your healthcare needs.

FAQs

Why Is Medicare Advantage Sometimes Not The Best Option?

Medicare Advantage can be costly when you're sick due to copay costs. Some plans have a limited network of doctors, which might not include your preferred choice. Also, it's hard to switch plans or add Medigap outside the initial enrollment period.

What To Do Before Switching From Original Medicare To Advantage?

Before switching to a Medicare Advantage plan, take these steps:

• Learn about your Medicare options.
• Think about your current and future healthcare needs.
• Understand what the least suitable Medicare Advantage plan might be for you.
• Talk to an advisor for guidance.

Why Should I Consider Medicare Advantage?

Medicare Advantage helps cover gaps in Original Medicare and often has a $0 premium. It's a good choice for healthy people who don't need frequent doctor visits.

Are Medicare Advantage Plans a Smart Money Move?

Medicare Advantage plans can be a good deal, especially with a $0 premium. But it's up to you to decide if it fits your budget and needs.

Whether it's a good investment depends on where you live, your health needs, and your financial situation.

Can I Choose Any Doctor With Medicare Advantage?

Usually not. Most plans have a specific group of doctors you can visit, so make sure your doctor is covered before scheduling an appointment.

Why Are Some Medicare Advantage Plans Free?

Many think Medicare Advantage plans are free, but that's not true. You still pay the Part B premium and costs.

These plans seem free because Medicare pays private companies to take on your health risk. Not all plans are low-cost, but they're made to look attractive to get people to enroll.

Final Words

There isn't one single "worst" Medicare Advantage plan, and not all advantage plans are bad.

However, because there's a lot of variation between plans, it's more common to run into problems with them compared to Original Medicare.

Before picking one, check all costs like co-pays and deductibles. Make sure your doctors are in the plan and your medications are covered.

If not, find out if the plan's doctors and medicines are okay for you. It's smart to work with a Medicare Advisor to choose the right plan for you.