FAQ Friday: The Downsides to Medicare Advantage Plans

I want to start this post by saying that I do not think Medicare Advantage plans (Medicare Part C) are bad. There are many Medicare Advantage plans out there that are very good plans and it really depends on the person’s situation and their needs on whether or not a Medicare Advantage plan is a good choice for them or not. My goal is not to bash Medicare Advantage plans but to educate. Unfortunately, it is all to common that agents will sell a Medicare Advantage plan to someone without fully giving them all of the information and the full effect of their choice.

Let’s start by explaining what a Medicare Advantage plan (Medicare Part C) is and how it works. A Medicare Advantage plan is a private alternative to Medicare. Medicare pays these carriers such as Aetna Coventry, Cigna Healthspring, United Healthcare, Humana etc. to provide seniors their benefits more affordably than they can provide them. Medicare then regulates these carriers to ensure that they are doing their job and they are doing it right.

Medicare takes the premium that you pay them and goes to each specific carrier and they create a “benefit package”. They then meet with doctors and they come up with a “fee structure” that the doctors will agree to accept, this is why most Medicare Advantage plans are HMOs and PPOs.

These are some of the risks to a Medicare Advantage plan:

  • If you want to upgrade to a Medicare Supplement, you have to medically qualify. If you can not qualify, you are stuck with Medicare Advantage plans.
  • You have a network of doctors and hospitals. You have to sign an annual contract with the carrier for coverage but your doctor does not. They can drop that carrier anytime and they do not have to check with you first.
  • Limited to doctors. If you are having heart surgery and the best cardiologist isn’t in your network, your only option is to be stuck with the mediocre doctor or pay more out of pocket for your surgery.
  • Inability to budget your healthcare costs. If you look at the Summary of Benefits, most plans will read: Lab work $0-$300. You have no way of knowing what your costs will be until the time of service. If you are on a fixed income, budgeting is very important. Especially when it comes to your health.
  • Limited drug coverage. If you choose a Medicare Advantage plan you are only able to choose their drug coverage. In most cases, the plans with great drug coverage with have limited or more expensive health benefits and vice versa. Whereas, if you opt for a Medicare Supplement, you get the choice of around 25 different drug plans.

The only real pros to the Medicare Advantage plans are lower premiums and sometimes carriers will throw in additional benefits such as some dental, vision or hearing. However, they can cancel those benefits at any time because Medicare doesn’t cover those benefits so the carriers are not required to cover them. The cut and dry of Medicare Advantage plans is that you are giving up predictability, flexibility, you have co-pays for most services, you have to get referrals and prior authorizations and possibly the option to upgrade, all for lower premiums. It is so important to research the plans and know all of your options before you make your final choice. None of this information is meant to scare anyone or sway them because as I said, my company sells Medicare Advantage plans. My goal is to educate people on the facts and these are the facts.