Medicare Advantage Plans are health insurance plans from private companies that contract with Medicare to provide Medicare Part A and Part B benefits. These plans, sometimes called “Part C” or “MA plans,” are an alternative way to get Original Medicare coverage. With over 28 million people enrolled in Medicare Advantage Plans in 2023, they have become an extremely popular option. However, Medicare Advantage Plans also come with some key disadvantages that you need to consider. In this article, we’ll discuss the biggest disadvantage of Medicare Advantage Plans compared to Original Medicare.

What is Medicare Advantage Plan?

First, let’s review the basics of what Medicare Advantage is. Medicare Advantage Plans are offered by private insurance companies and provide the same coverage as Original or traditional Medicare Part A and Part B. Some key things to know this plan as an alternative to Original Medicare:

  • Medicare Advantage Plans must cover all medically necessary services that Original Medicare covers.
  • Plans may have different costs, coverage rules and restrictions compared to Original Medicare.
  • Many plans include prescription drug coverage (Part D).
  • When eligible for Medicare Advantage Plans often have extra benefits not offered by Original Medicare, like vision, hearing or dental coverage.

When you sign up for Medicare Advantage Plan, you still have Medicare. But you get your Part A and Part B coverage through the private plan, not directly from Original Medicare.

There are different types of Medicare Advantage Plans:

  • HMO plans – Must use in-network doctors and hospitals only, except in emergencies.
  • PPO plans – Can use out-of-network providers, often at a higher cost.
  • Private Fee-for-Service plans – Can use any provider who accepts the plan’s payment terms and conditions.

The Biggest Disadvantage: Limited Provider Networks

Now, let’s discuss the biggest potential disadvantage of Medicare Advantage Plans compared to Original Medicare – limited provider networks.

With Original Medicare, you can see any doctor or hospital in the U.S. that accepts Medicare. It offers complete freedom of choice nationwide. You never have to check if your providers are “in-network.”

However, Medicare Advantage Plans have provider networks. Each plan contracts with a limited number of doctors, specialists and hospitals in a service area. If you use out-of-network providers, you’ll often pay much more, if the plan covers those services at all.

This means Medicare Advantage enrollees must use healthcare providers who participate in their plan’s network. You may not have access to the same doctors and hospitals as under Original Medicare.

For example, let’s say Dr. Smith has been your primary care physician for many years. If Dr. Smith does not accept a particular Medicare Advantage Plan you’re considering, you would likely need to find a new doctor within that plan’s network.

This network limitation is especially true with HMO plans, which generally do not cover any out-of-network care except emergencies. But even PPOs have networks and often charge more for out-of-network providers.

That’s the tradeoff with Medicare Advantage Plans – they can offer additional benefits beyond Original Medicare, but you may lose provider flexibility. For many enrollees, not being able to see their regular doctor or specialist is too high a price to pay for the extra perks.

Provider Networks Can Change Every Year

Another aspect of this disadvantage is that provider networks change yearly. Medicare Advantage Plans can and do make regular changes to their provider networks from one year to the next. Your plan may drop your doctor or hospital from the network at any time.

During the annual enrollment period each fall, Medicare Advantage Plans publish their provider directories for the upcoming year. As an enrollee, you need to carefully check during this period that your healthcare providers will still be in-network during the next plan year.

If not, you may need to either switch to another Medicare Advantage Plan that includes your doctors for the next year, or disenroll from Medicare Advantage and return to Original Medicare.

Having provider networks that shift yearly can mean more hassles and potential disruptions to your healthcare each open enrollment season. With Original Medicare, your doctors and hospitals don’t suddenly drop out of the program.

Provider Access Issues With Certain Plans

Certain types of Medicare Advantage Plans are more likely to have provider access issues for enrollees. Here are some examples:

  • HMO Plans – As mentioned, these plans typically only cover in-network care. HMO networks are often the most limited among Medicare Advantage Plans, so provider access challenges are most common.
  • Special Needs Plans (SNPs) – These are Medicare Advantage Plans that limit enrollment to people with specific diseases or conditions. While this focused approach can benefit members, SNPs often have extremely narrow provider networks.
  • Private Fee-for-Service (PFFS) Plans – These plans let you see any provider who accepts the plan’s terms and payment rates, but not every provider will. Many PFFS plans have provider access issues due to physicians unwilling to work with their payment structure.

If you enroll in one of these types of Medicare Advantage Plans, thoroughly research the provider network before signing up. Call doctors you use to confirm they participate with the plan.

Examples of How Limited Health Insurance Networks Are Problematic

To illustrate the problems limited networks can cause, here are some real-world examples:

  • Mrs. Thompson needs to see a top orthopedic surgeon who specializes in knee replacements, but he’s not in her Medicare Advantage Plan’s network. She now faces higher out-of-pocket costs for using an out-of-network specialist.
  • Mr. Andrews was diagnosed with cancer and started extensive treatment with an oncologist in January. But when picking a new Medicare Advantage Plan for next year, he learns that oncologist will no longer be in-network. His care will be disrupted in the middle of cancer treatment if he sticks with that MA plan.
  • Ms. Murphy’s Medicare Advantage Plan does not include the nearest hospital to her home in their network. When she fell and broke her wrist, she had to pass up her neighborhood hospital and travel twice as far to get in-network emergency care.
  • Dr. Carson decides not to accept any MA plans next year due to low reimbursement rates. As a result, hundreds of Medicare Advantage members who use him as their PCP must now find and switch to a new primary doctor that participates in their plan’s network.

As you can see from these examples, using healthcare providers outside your plan’s network can negatively impact quality of care, result in higher out-of-pocket costs, or cause care disruptions if your doctor leaves the network.

Strategies For Avoiding Provider Access Issues

If you enroll in a Medicare Advantage Plan, there are steps you can take to help avoid potential provider access issues:

  • Research plan provider networks carefully each year during open enrollment. Read the plan directory and call your healthcare providers to confirm they will still be participating for the next year.
  • Consider a PPO plan instead of an HMO plan for more out-of-network access, even though costs may be higher.
  • If possible, select a Medicare Advantage Plan that allows you to continue using your preferred doctors and hospitals.
  • Be prepared to switch plans if your providers do leave a plan’s network in order to maintain continuity of care.
  • Avoid plans with very narrow networks or poor reviews related to provider access issues.
  • Use in-network urgent care when possible instead of the ER for non-emergencies to contain costs.
  • If you need to transition to a new specialist or hospital that’s in-network, ask for referrals from your primary doctor or patient advocate.

The bottom line is that Medicare Advantage Plans can limit which providers you are able to see. This major drawback should be carefully evaluated before leaving the flexibility of Original Medicare.

Medicare Supplement Plans Offer Provider Choice

If you want guaranteed provider choice, Medicare Supplement Insurance (Medigap) Plans allow members to see any healthcare provider nationwide who accepts Medicare. Medigap Plans work alongside Original Medicare to cover out-of-pocket costs like deductibles and coinsurance.

Medigap does not have networks – any provider participating in Medicare also accepts Medigap. These plans preserve the complete healthcare provider access offered by Original Medicare.

Weighing the Pros and Cons of Medicare Advantage VS Original Medicare

Medicare Advantage offers benefits that Original Medicare does not, like caps on annual out-of-pocket spending, vision, dental, hearing benefits, health club memberships, and more. For some Medicare beneficiaries, those additional perks make the tradeoff of restricted provider networks worthwhile.

But for other Medicare members, the potential loss of provider choice and care access with Medicare Advantage is too big of a disadvantage. There is no “right” or “wrong” choice – it’s an individual decision based on your specific healthcare needs and preferences.

Before joining a Medicare Advantage Plan, have a thorough discussion with your doctors about whether they participate in the plan’s network. If provider choice is important to you, weigh how much you are willing to compromise on that to get the extra benefits Medicare Advantage offers.

Carefully compare plans each year during open enrollment to make sure your providers are still in-network for the next year. Be prepared to switch plans or return to Original Medicare if your healthcare providers do leave a plan.

While Medicare Advantage Plans have tradeoffs, the limited provider networks and lack of healthcare provider choice is undoubtedly the biggest potential disadvantage for Medicare beneficiaries to consider.

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 American Entitlements a Call at (469) 814-0289. 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 the difference between Medicare Part A and Part B?

Medicare Part A helps cover inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Medicare Part B helps cover certain doctors’ services, outpatient care, medical supplies, and preventive services. Together, Medicare Part A and Part B are known as Original Medicare.

How do I enroll in a Medicare Advantage Plan?

You can enroll in a Medicare Advantage Plan during the Annual Enrollment Period from October 15-December 7 each year. Medicare Advantage Plans, also known as Medicare Part C, are private health plans approved by Medicare that often include Part D prescription drug coverage.

What are the potential advantages of a Medicare Advantage Plan?

Medicare Advantage Plans may offer additional benefits not covered by Original Medicare like vision, dental, and hearing coverage. They also often have out-of-pocket limits that provide protection against high medical costs. Many Medicare Advantage Plans include prescription drug coverage as part of the plan which can be convenient for enrollees.

What is the difference between a Medicare Advantage Plan and Original Medicare?

Original Medicare is fee-for-service coverage run by the federal government, while Medicare Advantage is an alternative option run by private insurers approved by Medicare. Advantage Plans often have networks and require referrals, while Original Medicare allows enrollees to see any provider that accepts Medicare. Advantage Plans also typically include Part D prescription drug coverage.

When can I switch from a Medicare Advantage Plan back to Original Medicare?

If you’re enrolled in a Medicare Advantage Plan, you have a chance each year during the Medicare Advantage Open Enrollment Period (January 1 – March 31) to disenroll from your Advantage Plan and switch back to Original Medicare. This enables beneficiaries to change their coverage during this time if they become dissatisfied with their Advantage Plan.

What is a Medicare Part D prescription drug plan?

Part D is a voluntary outpatient prescription drug benefit available to all Medicare beneficiaries. Medicare Part D Plans are operated by private insurance companies approved by Medicare. They provide prescription drug coverage that may help lower your costs and protect against higher drug costs. You must have Medicare Part A and/or Part B to enroll in a Part D Drug Plan.

Which is better, a Medicare Advantage or Original Medicare Plan?

There’s no single best answer as individual needs vary – both have pros and cons. Original Medicare has more provider choice but lacks an out-of-pocket maximum. Medicare Advantage usually includes prescription coverage and may have lower costs, but networks are smaller. Consider coverage details as well as personal preferences when deciding between the options.

What types of Medicare Advantage Plans are available?

Common types of Medicare Advantage Plans include HMOs, PPOs, PFFS plans and SNPs. HMOs often have networks but no referrals needed. PPOs have in-network benefits but allow some out-of-network use for a higher cost. PFFS plans and SNPs cater to specific needs. Review the differences in plan structures and provider choices based on your healthcare needs and preferences.

How can I find the best Medicare Advantage Plan for me?

You can compare plans on Medicare.gov or work with a benefits advisor. Consider your prescription drug needs, doctors/providers you want to use, and any extra benefits you may want. Make sure any plan you choose covers the doctors and prescriptions you use. Narrow down your favorites before checking costs and other factors like quality ratings to find the top option.

What are some potential disadvantages of a Medicare Advantage Plan?

Potential disadvantages include smaller provider networks than Original Medicare, referral requirements for certain services, higher costs if using out-of-network providers, and less flexibility if you want to change plans during the year. Plans can change coverage or costs yearly, and may require pre-authorizations before receiving certain care. Disenrolling from Medicare Advantage may restrict future choices.

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