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KNOW THE DIFFERENCES.
Medicare Advantage is not the same as traditional Medicare. There are key differences that can have a real impact on how, when, and where you get the medical care you might need.
Each Medicare Advantage plan is also different. Comparing each plan’s covered benefits, limits, provider networks, restrictions, and cost-sharing requirements can be challenging, and it can be hard to know if a specific plan will meet your needs should you get injured or sick or become disabled.
What Seniors Need to Know Right Now
Medicare Open Enrollment: October 15, 2024 – December 7, 2024
Every year during open enrollment, current Medicare enrollees have the option to:
- Switch from one Medicare Advantage plan to another or
- Switch to traditional Medicare coverage or
- Switch from traditional Medicare coverage to Medicare Advantage coverage
Frequently Asked Questions Regarding Medicare and Medicare Advantage.
Isn’t Medicare Advantage (MA) a cheaper option for seniors?
Not necessarily. It’s true that MA plans have an annual cap on your out-of-pocket costs ($8,850 for 2024). But, you may incur unexpected costs if you see a doctor or specialist who isn’t in your plan’s network of providers. You may also incur unexpected costs if you need care while traveling or if you need to stay in the hospital longer than your plan allows. You might also incur costs by having to travel outside of your community to see a doctor who is in your plan’s network.
Can’t I just switch back to traditional Medicare if my plan isn’t working for me?
You can only switch back to traditional Medicare during the federal government’s “Medicare Open Enrollment” period–October 15 to December 7. The potential risk for enrolling in a Medicare Advantage plan, even temporarily, is that it can make getting supplemental Medigap coverage more difficult and expensive. Most seniors who choose traditional Medicare will also want Medigap coverage to help pay for out-of-pocket costs. Medigap coverage is most affordable when you first become eligible for Medicare. That’s because the cost isn’t dependent on any medical conditions you have, prescription drugs you use, or number of doctors you see. If you wait to purchase Medigap coverage until you switch from a Medicare Advantage plan to traditional Medicare, the cost of your Medigap coverage will be underwritten, meaning your medical history and pre-existing conditions factor into the cost. If you’ve used your Medicare Advantage plan for medical care, your Medigap policy will be more expensive than if you opted for traditional Medicare plus Medigap coverage when you first became eligible for Medicare.
Aren’t Medicare Advantage plans a better deal because they offer more services than traditional Medicare?
Many MA plans do offer “perks,” like gym or Silver Sneakers memberships, and some offer benefits not covered by traditional Medicare like hearing, vision, and dental. Medicare enrollees need to carefully weigh the value of these perks against the possible hefty out-of-pocket costs for hospital stays, surgeries, medical equipment, x-rays, lab services, ambulance transport, and other services often needed by individuals who are sick or who have an injury or disability. Medicare Advantage plans do not cover any care you might need when you travel. If you’re visiting family or friends in other cities or states and need medical care, your plan is unlikely to pay for it. Medicare Advantage plans also do not cover “swing bed services.” You might not think about swing bed services when you’re healthy. But, only traditional Medicare will pay for you to stay in the hospital for extra recovery time and to get rehabilitation services like physical therapy after a procedure like a knee replacement or after an illness. Swing bed services can take place in your local hospital, and you get the care and looking after you need to have a healthy long-term recovery. With Medicare Advantage coverage, you have to go home once the plan decides it is not medically necessary for you to be in the hospital.
There are so many choices for Medicare coverage. What does the hospital recommend?
Medicare coverage should provide peace of mind and help seniors access the care they need close to home with doctors and providers they know and trust. The safest choice is to select traditional Medicare and purchase a Medigap supplemental policy as soon as you become eligible for Medicare. If you want to choose a Medicare Advantage plan, carefully compare the choices and ensure your current doctors and providers are in the network and consider what your future health care needs might be and if all prescribed treatment and care would be covered adequately.
Saying Hello to Medicare Advantage Could Mean Saying Goodbye to Your Doctor.
While a lower monthly premium and all-inclusive prescription drug coverage can make Medicare Advantage (MA) plans an attractive option over traditional Medicare, these plans can drastically limit your health care network. This could mean saying goodbye to trusted doctors and providers you’ve known for years who may not be included in your Medicare Advantage plan’s network.
Network Limits
Unlike traditional Medicare that lets you see almost any doctor anywhere in the country, Medicare Advantage plans limit how and where you get care because they restrict your choice of doctors and hospitals to ones they’ve picked.
Only 46 percent of doctors that accept traditional Medicare accept some Medicare Advantage plans.
This means that if your local doctor is not in the Medicare Advantage plan’s network, you may have to travel far from home for care you would have been able to get here at home with traditional Medicare.
Network restrictions also limit your ability to receive care when travelling. If you’re visiting grandchildren and need medical care, you may not be able to get it because your plan doesn’t include doctors in that town. Same thing if you’re on vacation. Traditional Medicare, on the other hand, allows you to see any doctor virtually anywhere in the country.
Prior Authorization and Coverage Denials
Even if your doctor is included in your Medicare Advantage plan’s network, Medicare Advantage plans can limit the care your doctor can provide.
99 percent of Medicare Advantage plans require prior authorization for services covered by traditional Medicare, like skilled nursing, short-term hospital stays, and durable medical equipment.
This means your doctor must get permission from your Medicare Advantage plan before you can get recommended medical equipment or treatment, such as oxygen equipment, surgery, or physical therapy. The Medicare Advantage plan staff making these care decisions typically are not physicians and may not be medical professionals at all.
Each Medicare Advantage plans also uses its own guidelines to make coverage decisions, and these guidelines are not the same used by traditional Medicare. The result is that Medicare Advantage plans deny coverage much more often than traditional Medicare, including care that traditional Medicare covers.
Talk to Your Doctor About the Risks of Medicare Advantage
Medicare Advantage plans are not a substitute for traditional Medicare.
Talk to your doctor before choosing a Medicare Advantage plan and make sure you have all the facts before deciding about your health care coverage.
Learning more about Medicare Options
For many seniors, Medicare programs offer the opportunity to access care that leads to a healthy lifestyle. Depending on needs and location, the decision on which plan works best for you or a loved one can make a huge difference in determining whether the expected benefits will meet projected needs. Seniors may perceive incentives and lower costs associated with the Medicare Advantage as benefits, only to discover the program's plans often lead to delays in care, excessive denials, and frustration. These plans also create onerous administrative burdens for health care providers, destabilizing finances for rural hospitals and their ability to provide care in their communities.
Traditional Medicare May Offer Texans Greater Freedom Than Medicare Advantage
When you turn 65, you have health care choices: Traditional Medicare or Medicare Advantage? Having the freedom to choose the health care coverage that works best for you only works when you have all the information to make an informed choice.
When you turn 65, you have health care choices: Traditional Medicare or Medicare Advantage?
Having the freedom to choose the health care coverage that works best for you only works when you have all the information to make an informed choice. Taking the time to assess your options will help ensure a better health care experience as you age.
One big difference between Traditional Medicare and Medicare Advantage is the availability of health care providers. For many, having the freedom to keep their doctor or choose one based on their needs is an important part of maintaining independence and a feeling of control over their health. Traditional Medicare works with nearly every hospital and doctor in the country. Medicare Advantage plans’ limit their networks of health care providers by design. In fact, less than half of the country’s doctors work with any Medicare Advantage plan. Often, people sign up for Medicare Advantage plans without realizing they will be forced to find another doctor, and doctors and other health care providers are not locally available.
Medicare Advantage plans choose which doctors, therapists, home health care providers, and hospitals they want to work with, and your options for care are limited to their choices. Even if you’ve had the same doctor your entire adult life, if he or she isn’t in your Medicare Advantage plan’s network, you’ll need to pick a different one.
Another point to consider, particularly, for the millions of Americans with chronic conditions, is continuity and consistency of care. When Medicare Advantage plans’ provider networks change year over year, this continuity of care can be threatened. To be sure you can have the doctor you want:-Ask insurance brokers or Medicare Advantage sales agents about provider availability in your local community.-Clarify the availability of specialists, such as home health providers, podiatrists, and those you might depend on most for other specialized care nearby.
Questions to Ask an Insurance Broker Before Committing to a Medicare Advantage Plan
It can be confusing to navigate healthcare as you approach Medicare age. The help of an insurance broker might sound appealing to guide you through the process. But, even trusted local insurance brokers might not present the full picture when it comes to weighing your options–especially between traditional Medicare and Medicare Advantage. The risk is that making the wrong choice today might restrict your future options or wind up costing you more down the line. Understanding the broker’s role is important. You want to have impartial information and choices so you can make the best decision for you. The devil is in the details, but here are a few simple questions to help determine what’s best for you.
- How many insurance companies do you work with?
- What plans do you offer? Are these all the plans available in our area?
- How are you paid?
Rural Texas has fewer health care providers than in cities. Make sure your preferred doctor or hospital is included in the Medicare Advantage plans’ networks. Here are three questions to ask:
- Are my current health care providers in the plans’ networks?
- Are they accepting new patients from the plans?
- Which specialists, hospitals, home health providers, and skilled nursing facilities are in the plans’ network?
- How easy is it to see specialists, and are they available locally or within a reasonable distance?
If you travel frequently or plan to move, understanding the plan’s coverage in different locations is essential. Here are questions you should ask about the plan’s likelihood of covering your medical care if you’re out of town.
- Does the plan cover services when I travel outside my local area?
- What happens to my coverage if I move to a different region or state?
The price you pay through premiums and deductibles can initially be lower with a Medicare Advantage plan, but costs can add up especially if medically necessary services aren’t covered. Here are questions on cost to ask:
- What is the monthly premium?
- Is there an annual deductible?
- How much are doctor visits, hospital stays, and prescription drugs?
- What is the annual out-of-pocket maximum?
- If my plan doesn’t cover a service my doctor says I need, do I have to pay out-of-pocket?
Medicare Advantage plans often offer perks not covered by Traditional Medicare. Ask about the following:
- Are vision, dental, and hearing services covered?
- Are there wellness programs or fitness memberships available that I can access locally?
- Is telehealth included, if I need it to access specialists?
Choosing a plan with good customer service and a strong reputation is another important consideration. Here are questions to ask about the plan’s reputation.
- What is the plan's star rating?
- How responsive and helpful is the plan’s customer service?
- What do current members say about the plan?
It is important to know the implications of leaving a Medicare Advantage plan and switching back to Traditional Medicare. Here are some questions to ask:
- What is the cost of supplemental (MediGap) coverage today?
- What is the likely cost of MediGap coverage in the future if I want to switch back to Traditional Medicare?
If you have other forms of insurance, such as employer-sponsored coverage or Medicaid, it is essential to understand how the Medicare Advantage plan will work with them. Ask the following:
- How will the plan coordinate with my other insurance?
- If I am eligible for both Medicare and Medicaid, how will this plan address my needs?
Protecting Your Future Self: How Traditional Medicare Might be the Better Long-Term Coverage Choice Than Medicare Advantage
Medicare Advantage plans are not a substitute for traditional Medicare.
Talk to your doctor before choosing a Medicare Advantage plan and make sure you have all the facts before deciding about your health care coverage.