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Is Medicare Advantage an Actual Advantage?

Updated: Nov 6, 2023

Over the last several years, there has been a concerted effort by the government and insurance companies to push senior citizens into choosing Medicare Advantage plans over traditional Medicare. There are many reasons why this is happening, but the main question is whether or not these non-governmental plans are actually an advantage over the coverage offered by the original Medicare program? Given the push towards Medicare Advantage plans, the enrollment has increased significantly. As of 2018, enrollment has reached 20 million, tripling since 2005. By 2028, 42% of the population eligible for Medicare will be enrolled in some form of Medicare Advantage plan. Because senior citizens often do not know the difference between traditional Medicare and Medicare Advantage plans, they might make a choice that is ultimately not in their best interest.

Where is the advantage?

The first step in making the right choice is knowing what benefits Medicare Advantage provides versus what the original Medicare coverage provides. Unlike the original Medicare coverage that is paid for by the government (Parts A and B), Medicare Advantage (Part C) coverage is through private insurance companies. Medicare Advantage plans are supposed to offer the same coverage as original Medicare, but they do have some downsides as compared to original Medicare:

  • They require copays and coinsurance fees

  • Plans are difficult to contrast from each other given the varied options within each plan

  • More likely than not there is no nationwide coverage for necessary services and enrollees in Medicare Advantage plans must treat within a network of providers

  • The network of providers is generally only regionally based

  • Most plans require referrals to see specialists

  • Yearly changes in medical and drug coverage causes no continuity of services

  • It is difficult to switch Medicare Advantage plans due to changes in services covered.

One major complaint of Medicare Advantage plans is that they benefit the healthy. Critics say that the copay and deductible structure under these plans discourages sick people from applying. But when otherwise healthy people become sick under these plans, there is often a surprise sticker shock due to the increase in copays and deductibles that have to be paid. Critics of the government’s push of consumers toward Medicare Advantage plans argue that it is the job of the government to educate the elderly on the advantages and disadvantages of both traditional Medicare and Medicare Advantage equally, not to favor one option over the other. Also, experts indicate that Medicare Advantage plans may not save the government money and may not be the best option available, particularly for those people with serious, chronic injuries, who are switching away from Advantage plans at higher rates. These insurers may offer a plan that has a zero-dollar monthly premium, but if you get sick, the co-pays might put you into financial trouble. Another problem with Medicare Advantage is that there are no standard rules applying to all plans that dictate what treatment is “medically necessary.” Therefore, each individual insurer may have different criteria when performing a utilization review on a particular treatment, and using these scattered rules to deny treatment, treatment that would have been approved under a traditional Medicare plan. Recently, it has been determined that Medicare Advantage plans have been overbilling the government by exaggerating the level of patient illnesses or billing for treatment of medical conditions that patients do not have. This overbilling has reached the level of tens of billions of dollars. Read the fine print Before you decide which option to choose, read the fine print on every Medicare Advantage plan that you are considering. Obtain an exhaustive list of each plans’ co-pays and deductibles and then compare those, if possible, to what would have to be paid under traditional Medicare. Another thing you should do is contact experts in the field who can give you answers to your questions without any bias from the insurance industry. The lawyers and staff at Anderson Elder Law have been advising clients for decades on issues of Medicare, Medicaid and long-term planning. Learn more about our Medicare Optimization Services. We are available to sit down with you to provide detailed, easily understood answers to these complex questions and can help you develop a plan moving forward with your long-term care. You can contact us by form or call us at 610-566-4700.

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