The Pros and Cons of Medicare Advantage Part C
The Top 5 Advantages Of Medicare Advantage Part C
#1 Lower Premiums: Usually lower premiums compared to a Medicare Supplement plus a Part D Drug Plan. Substantially lower premiums over time can save you thousands of dollars. Plus, the cost savings can be better utilized for other retirement needs—like Long-Term Care insurance, investing, paying off a mortgage, etc. More on this later.
#2 Lower Out-Of-Pocket Costs: May have lower out-of-pocket costs than Original Medicare. All Medicare Advantage plans have a Maximum Out-of-Pock (MOOP) that serves as your financial protection in the event of a serious and costly health and medical situation. Once you hit that limit, the insurance company pays 100% of the costs. With Original Medicare THERE IS NO OUT OF POCKET LIMIT! But, if you add a Medicare Supplement policy, you are protected from high out-of-pocket costs.
#3 Extra Benefits: Depending on where you live and the plans available to you, as already mentioned, you receive extra benefits like dental, vision, hearing, health club memberships, transportation and more.
#4 No Three Day Inpatient Hospital Stay To Receive Skilled Nursing Care: This can be a big one! And, I believe Medicare should abolish this rule.
Here’s what can happen—If you are on Original Medicare and even with a Medicare Supplement and you need Skilled Nursing, then you must have “a 3-day minimum, medically necessary, inpatient hospital stay for a related illness or injury” to be covered by Medicare and your Medicare Supplement for Skilled Nursing services and costs.
Why is this a big deal? Well a couple things can happen.
1. You may have to stay in the hospital for three days for no reason at all and incur the costs of that stay.
2. You may end up or be in the hospital and they may discharge before your 3-day stay is up and send you off to the Skilled Nursing center. When that happens, YOU WILL PAY 100% of the Skilled Nursing costs from day 1.
Whereas with a Medicare Advantage Plan you can be admitted to a Skilled Nursing facility straight from your home, your doctors office or from the hospital even if you haven’t been in for 3 days.
# 5 Better Healthcare Outcomes: Because Medicare Advantage Plans are more managed care than Original Medicare, you have better healthcare outcomes. This is especially important for people with chronic conditions.
Examples:
43% lower rate of avoidable hospitalizations for any reason
38% less likely to have an inpatient hospital admission
21% more physician visits within 14 days of discharge
33% fewer emergency room visits
2% higher vaccination rates among high-needs, high-cost beneficiaries
11% fewer inpatient hospitalization stays for beneficiaries with major, complex medical conditions
This data is often overlooked and omitted by many agents who focus purely on Medicare Supplements. Even if your out-of-pocket costs were higher with a Medicare Advantage Plan compared to Original Medicare and a Medicare Supplement… would that be worth having a better healthcare outcome? (https://bettermedicarealliance.org/)
The Top 6 Disadvantages Of Medicare Advantage Part C
Not one option or plan is perfect or the best solution for everyone. Even with many of the advantages to Medicare Advantage there are undoubtedly some disadvantages.
#1 Your Doctor or Hospital May Not Be In The Network: Most of the Medicare Advantage Plans have a network of doctors and hospitals. You may find that your preferred provider does not accept the plan at all…or, you have to pay a higher copay at your preferred provider or hospital. To avoid this, you should pick a plan where your preferred doctors and hospitals are In-Network.
You really should avoid plans that don’t cover you at speciality and teaching/university hospitals. You may not be needing care from one of those hospitals now, but if you ever need it, you will want to be able to go and be covered. Examples would be places like the Mayo Clinic, the Cleveland Clinic, Cancer Centers and University Hospitals.
In Virginia, where I live, the main and number 1 specialty and teaching hospital is the University of Virginia hospital system. And in the state of Virginia, there are many Medicare Advantage Plans that don’t cover you at the University of Virgina hospital or costs you significantly more to go there than another plan. I typically only recommend plans that have the University of Virginia In-Network.
#2 Less Predictable Costs and Your Out-Of-Pocket Costs Could Be Higher: So, one of the advantages of Medicare Advantage was that your out-of-pocket costs could be lower…but by the same token, they could be higher.
When you have Original Medicare with the right Medicare Supplement, you pretty much know what your medical costs are going to be each year regardless of any medical issue. This is peace of mind for a lot of people.
Sure, you could have a $0 premium plan, but if you have a major medical situation you could incur copayments into the thousands of dollars. Whereas, with a Medicare Supplement, in most cases, it might only be into a few hundred dollars.
If you have a health situation that demands you visit the doctor or hospital routinely then, depending on where you live and the Medicare Advantage Plans available, you should seriously consider a Medicare Supplement. To best way to determine this is to simply give me a call to discuss your particular situation.
#3 Your Drug Coverage May Not Be As Good As A Stand-Alone Part D Drug Plan: Drug coverage varies widely from plan to plan. It’s extremely important that you have the best drug coverage you can get.
Unfortunately, I see many people who see the wrong agent, call an 800# or get solicited by a telemarketer and end up with horrible drug coverage.
In my 11 years of experience I have found that, for a lot of my clients, their number 1 cost is their prescriptions. It’s not doctor visits. It’s not hospital visits…it’s their medications. You may go to the doctor a few times a year and incur a few hundred dollars per year in copays. But, your share of your drug costs could be in the thousands of dollars. Being on the wrong plan could increase your drug costs by thousands!
Just because one plan’s premium is lower or the benefits seems better, does not mean your drug coverage is the best or even comparable to the best.
Many people make the foolish mistake of switching plans because the plans benefits are supposedly better and then when the new plan starts they find out that their drug costs went through the roof.
When you work with me, I review your drug coverage to make sure you have one of the lowest overall drug costs available. Few agents do this for their clients! Especially the ones contacting you over the phone.
#4 Your Plan May Radically Change From One Year To The Next: For the most part, Original Medicare has been the same since 1965. The Part B premium, the Part B deductible, the Part A deductible and Part A copays go up a little each year…but the benefits pretty much stay the same.
When you get a Medicare Supplement, the benefits don’t change from year-to-year…only the premium does.
So, you could have an excellent Medicare Advantage Plan this year, but next year it may not be as good or there may be a better option. Benefits you had may be gone or reduced. That’s why it’s important to review your Annual Notice of Change each Fall and call me to make sure you have the right plan for your particular needs.
#5 You Will Be Solicited By Telemarketers More and More Frequently: Ugh! This may be the worse thing about having Medicare Advantage or just simply being on Medicare.
No doubt you have seen all those TV ads with celebrities Joe Namath, Jimmy “JJ” Walker, and the like that tell you to “call now” because “you may be entitled to more benefits.” My advice—DON’T EVER CALL AN 800# from an ad you see on the TV. And don’t ever talk to a telemarketer about your Medicare. Chances are, you will make a mistake!
Because you have Medicare or Medicare Advantage, the telemarketers love to call you to get you to switch to a “better” plan. These ads and these calls are increasing and causing a lot of Medicare beneficiaries trouble. They are misleading and they don’t give you all the facts. They don’t tell you that certain hospitals or doctors are out-of-network. They don’t compare your drug cost from one plan to another. More and more frequently, I have my clients calling me about these ads or the telemarketers. Recently, one of my clients called me after he called one of the 800# numbers from a TV ad. The agent at the 800# switched my clients plan without his permission. They are very deceptive! Do yourself a favor… avoid them and call me.
#6 You May Have To Deal With Prior Authorizations: One big difference between Original Medicare and Medicare Advantage is the greater likelihood you will at some time have to deal with some Prior Authorizations. "Certain procedures, services and drugs may need advanced approval from your plan." Your provider should be the one taking care of it. The issue is, the Prior Authorization requirement can cause delays and/or denials of care. For more information on this, see the links at the bottom of the page.
In the end, even with these disadvantages, when you understand them and we work together to find the most suitable plan for your unique needs, most of these disadvantages can be lessened if not eliminated altogether.
News on Prior Authorizations:
