When you become eligible for Medicare, one key decision is whether to stick with Original Medicare or enroll in a Medicare Advantage Plan. But is Medicare Advantage the right choice for you?

Medicare Advantage offers some potential advantages like built-in prescription drug coverage and extra benefits. But these private Medicare Plans also have some limitations to consider. Read on for an in-depth look at the pros and cons to understand if Medicare Advantage is a good option for your situation.

What is Medicare Advantage?

Medicare Advantage, sometimes called Medicare Part C, refers to Medicare health plans offered by private insurance companies that are approved by Medicare. They bundle your Part A and Part B coverage and often include prescription drug coverage as well.

With Medicare Advantage Plans, you generally must get care from doctors and facilities within the plan's network, except in emergencies. Out-of-network care typically requires prior authorization.

Medicare pays these private insurers a set fee per enrollee to provide your Medicare benefits. Medicare Advantage Plans may cover everything Original Medicare does, but costs and rules differ.

Medicare Advantage enrollment has grown to over 28 million people, or about 48% of all Medicare beneficiaries, as of 2022. Some of the biggest providers include UnitedHealthcare, Humana, Kaiser Permanente, Blue Cross Blue Shield, and many more.

Pros of Medicare Advantage Plans

What are some potential advantages of Medicare Advantage Plans compared to Original Medicare?

Extra Benefits

Many Medicare Advantage Plans include extra benefits not offered by Original Medicare such as:

• Dental, vision, and hearing coverage

• Gym membership

• Transportation to doctor visits

• Over-the-counter allowances

• Meal delivery after hospital stays

These extra perks often come at no added premium cost. However, the value of extra benefits can vary greatly by plan.

Lower Out-of-Pocket Costs

In many cases, Medicare Advantage Plans have lower out-of-pocket costs for services like:

• $0 premiums

• Lower deductibles

• Fixed copays for doctor visits and procedures

Medicare Advantage out-of-pocket maximums limit how much you pay annually, which provides cost protection. Original Medicare has no out-of-pocket cap.

Prescription Drug Coverage

Unlike Original Medicare, most Medicare Advantage Plans include Part D prescription drug coverage with the medical benefits, so you don't have to get a separate drug plan.

Telehealth Options

Most Medicare Advantage Plans now offer telehealth benefits with phone or video visits with physicians. This provides convenient access to care.

Coordinated Care Approach

Medicare Advantage Plans often aim to provide coordinated care by having you get care within their network of doctors and hospitals. This may promote quality and efficiency.

Cons of Medicare Advantage Plans

However, Medicare Advantage also has some potential drawbacks to think about:

Limited Provider Network

Medicare Advantage Plans have provider networks, so you generally must see doctors and hospitals contracted with the insurer, except in emergencies. This results in less flexibility and choice.

Prior Authorization Requirements

For certain services, drugs, tests and procedures, Medicare Advantage Plans often require you get approval in advance before they will cover it. This can add delays.

Out-of-Network Costs

Seeing out-of-network providers results in higher copays or coinsurance. Some plans do not cover out-of-network services at all except in emergencies.

Restrictions on Covered Services

While Medicare Advantage Plans must cover medically necessary services, they can set some coverage rules and limits that may restrict care access.

Medicare Advantage May End

Medicare Advantage Plans can decide not to continue serving an area in future years, forcing you to find a new plan option.

Is Medicare Advantage or Original Medicare Better?

Whether Medicare Advantage or Original Medicare is better depends on your preferences and situation. Here's a quick comparison:

Original Medicare

• See any doctor accepting Medicare

• Only pay deductible/coinsurance amounts

• Add separate Part D Plan for drug coverage

• Can pair with supplemental Medigap policy

Medicare Advantage

• Limited provider network

• Copays for services instead of 20% coinsurance

• Typically includes prescription drug coverage

• Often has extra benefits like dental and vision

Those who want flexibility and simplicity may prefer Original Medicare plus a Medigap Plan. People seeking lower costs, benefits like vision and dental, and don't mind networks may prefer Medicare Advantage.

Key Factors in Deciding on Medicare Advantage

As you decide if Medicare Advantage is right for you, here are some key factors to consider:

Do your doctors accept the plan?

Verify all your physicians, specialists, hospitals, and pharmacies are in-network with any Medicare Advantage Plan you consider.

What will your total out-of-pocket costs be?

Compare monthly premiums, deductibles, copays/coinsurance, and maximum out-of-pocket limits to estimate total costs.

Do your medications have affordable copays?

Make sure all prescription drugs you take are on the plan's formulary and have reasonable copay tiers.

Does the plan include benefits you need?

Evaluate extra benefits like dental, vision, hearing and transportation against your healthcare needs.

Does the plan have high quality ratings?

Opt for 4 or 5-star Medicare Advantage Plans for better quality and satisfaction.

Enrolling in Medicare Advantage

You can sign up for Medicare Advantage Plans when first eligible for Medicare, during Medicare's Annual Election Period from October 15 to December 7 each year, or in some cases during Special Election Periods.

To enroll, you must:

• Have Medicare Parts A and B

• Live in the plan's service area

• Not have End-Stage Renal Disease

Use Medicare's Plan Finder tool to compare Medicare Advantage Plans available in your Zip code.

Changing Medicare Advantage Plans

If you already have a Medicare Advantage Plan but want to switch, you can either:

• Change plans during Medicare's Annual Election Period

• Drop your Medicare Advantage Plan and switch back to Original Medicare coverage

You may also qualify for a Special Needs Plan if you have certain chronic conditions.

Leaving Medicare Advantage

To leave a Medicare Advantage Plan, you can switch back to Original Medicare during the Annual Election Period or if you qualify for a Special Enrollment Period. You will automatically return to Original Medicare if:

• You move out of your plan's service area

• You lose special needs status required to enroll in a Special Needs Plan

• Your plan withdraws from offering Medicare Advantage in your area

Be aware you may not be able to get Medigap Plan available in your area if you switch back to Original Medicare depending on your situation.

Weighing Medicare Advantage vs. Medigap

Since Original Medicare leaves you responsible for deductibles and 20% coinsurance, many enrollees add a Medigap supplemental policy to reduce out-of-pocket costs. How do Medicare Advantage and Medigap compare?

Medicare Advantage

• Often has $0 premiums

• Covers prescription drugs

• Offers extra benefits

• Networks limit providers

Medigap

• Provides flexible provider choice

• No networks

• Pays coinsurance amounts

• Has extra monthly premiums

Look at all costs as well as healthcare needs and doctor preferences when deciding between Medicare Advantage or Medigap.

Is Medicare Advantage Right for You?

The best Medicare alternative for you depends on factors like:

• Income and ability to pay premiums

• Health conditions and prescription needs

• Preferred doctors and hospitals

• Interest in extra benefits

• Geographic location

Carefully compare costs, coverage rules, provider networks, quality ratings, and benefits when evaluating Medicare Advantage health insurance plans in your area. Weigh the pros and cons to decide if enrolling in Medicare Advantage or sticking with Original Medicare makes more sense for your situation.

Key Takeaways on Medicare Advantage Plans

• Medicare Advantage Plans are private Medicare Plans that bundle Parts A, B, and often D benefits but have limited provider networks.

• Medicare Advantage pros include extra benefits, lower out-of-pocket costs, prescription drug coverage, and telehealth.

• Cons include networks restricting provider choice, prior authorization rules, and potential gaps in healthcare coverage.

• Compare Medicare Advantage pros, cons, costs, and benefits to Original Medicare when making your choice.

• Look at physician access, prescription coverage, total costs and additional benefits when evaluating Medicare Advantage Plans.

• You can enroll in Medicare Advantage when first eligible, during Annual Election Period, and some Special Enrollment Periods.

• Weigh your preferences and healthcare needs to decide if a Medicare Advantage Plan is a good option for you.

The bottom line is Medicare Advantage has tradeoffs to consider versus Original Medicare. Understanding all the factors involved allows you to determine whether or not Medicare Advantage coverage aligns with your healthcare priorities.

We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Brexden Insurance a Call at (870) 919-7177. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.

FAQs

What is a Medicare Advantage Plan?

A Medicare Advantage Plan is an alternative to Original Medicare (Part A and Part B) offered by private insurance companies. These plans often include additional benefits such as prescription drug coverage, dental, vision, and hearing benefits, and sometimes even gym memberships.

What are the pros and cons of Medicare Advantage?

Pros of Medicare Advantage include additional benefits, potentially lower out-of-pocket costs, and the convenience of having all Medicare benefits bundled into one plan. Cons may include limitations on healthcare providers and networks, potential for higher costs if seeking care outside the plan's network, and varying coverage options depending on the plan and location.

How do Medicare Advantage Plans differ from Medicare Supplement Plans?

Medicare Advantage Plans provide all-in-one coverage that may include prescription drug benefits and additional services not covered by Original Medicare, while Medicare Supplement Plans (Medigap) work alongside Original Medicare to cover gaps in coverage such as co-payments, deductibles, and co-insurance.

What are the disadvantages of Medicare Advantage Plans?

Disadvantages of Medicare Advantage Plans can include limitations on healthcare providers, networks, and potential higher costs when seeking care outside the plan's network. Additionally, coverage options, benefits, and costs can vary based on the plan and location.

Can I still enroll in a Medicare Advantage Plan if I already have Original Medicare (Part A and Part B)?

Yes, you can choose to disenroll from Original Medicare and enroll in a Medicare Advantage Plan during the annual enrollment period. Keep in mind that you cannot have both Original Medicare and a Medicare Advantage Plan at the same time.

What should I consider when choosing a Medicare Advantage Plan?

When choosing a Medicare Advantage Plan, consider the specific benefits offered, the network of healthcare providers and facilities, prescription drug coverage, and the plan's costs including premiums, deductibles, and co-payments. It's important to select a plan that suits your individual healthcare needs and budget.

Are Medicare Advantage Plans bad?

Whether Medicare Advantage Plans are "bad" depends on individual needs and preferences. While they offer additional benefits and potential cost savings, they also come with limitations on providers and networks. It's essential to carefully evaluate the pros and cons of each plan before making a decision.

What happens if I don't like my Medicare Advantage Plan?

If you are dissatisfied with your Medicare Advantage Plan, you can switch to another plan or return to Original Medicare during the annual enrollment period. It's crucial to review and compare different plan options to find one that better suits your needs.

Do all Medicare Advantage Plans include prescription drug coverage?

No, although many Medicare Advantage Plans include prescription drug coverage, not all plans automatically include this benefit. It's important to review the specific details of each plan to determine if prescription drug coverage is included or if it can be added for an additional cost.

Can I switch from a Medicare Advantage Plan back to Original Medicare?

Yes, you can switch from a Medicare Advantage Plan back to Original Medicare during the annual enrollment period. Additionally, certain circumstances, such as moving out of the plan's service area, may qualify you for a special enrollment period to make changes to your coverage.