You may have heard that Medicare Advantage plans are bad, and they can be if you enroll without fully understanding your options and exploring whether the plan you’re considering meets your needs.
Choosing a Medicare plan is not a simple, one-size-fits-all process. Despite the potential benefits Medicare Advantage plans offer, they may not be the right fit for every individual’s unique healthcare needs and personal circumstances.
Many Medicare recipients choose Medicare Advantage plans to take advantage of healthcare benefits not included in Medicare Part A and Part B, such as dental, vision, and hearing coverage. However, it’s essential to remember that Medicare Advantage plans may also come with limitations, such as network requirements and out-of-pocket costs, which could impact your decision.
The following guide looks at common criticisms of why Medicare Advantage plans are bad as well as the benefits they offer, so you can make an informed decision about your Medicare coverage.
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Original Medicare vs. Medicare Advantage at a Glance
No; you can enroll in a stand-alone Part D plan
Sometimes; some plans include Part D benefits or you can enroll in a stand-alone Part D plan
Sometimes; some plans include vision, dental, etc.
Part A: Usually $0, but some people pay $278 or $506 per month. Part B: Usually $164.90
Varies; some plans charge supplemental premiums in addition to Part A and/or B premiums
Part A: $1,600 per benefit period. Part B: $226 per year
Varies; some plans have a $0 deductible
Copay and Coinsurance
Yes; varies by service
Yes; varies by plan and service
Annual out-of-pocket Maximum
None; you can enroll in Medigap to reduce out-of-pocket costs
Varies; out-of-pocket maximums can be as high as $8,300
Compatible with Medigap
Initial Enrollment Period
Annual Enrollment Period
Oct. 15 to Dec. 7
Oct. 15 to Dec. 7
General Enrollment Period
Jan. 1 to Mar. 31 (If you already have a Medicare Advantage plan)
Jan. 1 to Mar. 31; in certain circumstances
Medicare Advantage Open Enrollment Period
Jan. 1 to Mar. 31
Special Enrollment Periods
Yes, in certain circumstances
Yes, in certain circumstances
At a basic level, Medicare coverage can be divided into two categories: Original Medicare, which consists of Medicare Part A and Part B, and Medicare Advantage plans, also known as Medicare Part C.
Original Medicare is offered directly through the federal government. It includes hospital insurance (Part A) and medical insurance (Part B) but does not include Part D prescription drug coverage. Individuals covered under Original Medicare can purchase Part D coverage separately if needed. Original Medicare also does not cover services such as routine vision, dental, or hearing care.
Medicare Advantage plans are Medicare health plans offered by private insurance companies and overseen by the federal Medicare program. By law, Medicare Advantage plans must include the same services covered under Original Medicare. Many Part C plans also include Part D coverage and may also include vision, dental, and hearing services, as well as some additional benefits, such as wellness programs.
Many people pay no monthly premium for Medicare Part A and $164.90 per month for Part B. Some types of Medicare Advantage plans are available at no extra cost beyond your Part B premium, while others charge an additional monthly premium. Other out-of-pocket costs may include premiums, copayments, coinsurance, and deductibles. The cost-sharing amounts for Original Medicare are pre-set, while they can vary from one plan to the next under Medicare Advantage.
Original Medicare is compatible with Medigap, which can help offset out-of-pocket costs. On the other hand, Medicare Advantage is not compatible with Medigap, so you cannot have a Medigap and a Medicare Advantage plan at the same time. However, it’s important to note that Medicare Advantage plans do have an annual out-of-pocket maximum, which inherently limits out-of-pocket costs. In 2023, there are no out-of-pocket maximums associated with Original Medicare.
Why Medicare Advantage Might Be Bad For You
While Medicare Advantage plans provide a host of potential benefits, they have faced certain criticisms. Before deciding to enroll in Medicare Part C, consider these potential concerns.
Limited Options to Seek Care
Some Medicare Advantage plans require participants to seek medical care from healthcare providers within the plan’s network. In-network providers have agreed to offer services at pre-approved rates and do not pass additional charges to plan participants.
Plan networks ensure participants can pay a predetermined copayment or coinsurance amount without worrying about unexpected medical bills. However, some individuals see the network restrictions as a drawback since they may limit the ability to seek care from out-of-network providers without incurring additional costs. This may be particularly concerning for individuals who are on a fixed income.
Higher Out-of-Pocket Costs
Since cost-sharing requirements can vary among Medicare Advantage plans, a plan may have copayments or other costs not found in Original Medicare. Individuals covered by Original Medicare can also purchase a Medigap policy, which can cover a significant amount of your copayments and coinsurance costs.
Individuals are not allowed to purchase Medigap and Medicare Advantage together, potentially exposing you to high out-of-pocket costs. However, the annual out-of-pocket limit included in Medicare Advantage plans can help keep excess costs in check.
Service Area Restrictions
Medicare Advantage plans with provider networks are less portable than Original Medicare, which does not have network requirements. Individuals who frequently travel or are considering relocating may find that network restrictions disrupt coverage or lead to additional out-of-pocket costs.
However, in an emergency, Medicare Advantage plans typically cover necessary medical care regardless of your location. Some plans also offer travel benefits or have partnerships with providers in other areas, which could potentially offset some of these concerns. Careful planning may help mitigate these worries.
The networks, service areas, copayments, and additional benefits associated with Medicare Advantage plans can add an extra layer of complexity compared to Original Medicare. With a Medicare Advantage plan, you need to be vigilant about the plan’s cost-sharing structure and your potential financial liabilities related to various services and treatments.
While navigating Part C plans can feel a bit overwhelming, many Medicare Advantage providers offer dedicated customer care services and have representatives ready to assist plan participants in understanding the ins and outs of the plan.
Benefits to Consider With Medicare Advantage
Despite the potential concerns, several important benefits make Medicare Advantage plans attractive to many Medicare recipients. Here’s a look at a few reasons why you may consider a Part C plan for your healthcare coverage.
More Complete Coverage
Medicare Advantage plans generally provide a broader range of coverage compared to Original Medicare. For example, Part C plans typically include Part D prescription drug coverage, which is a critical aspect of healthcare for many retirees. It’s also common for Medicare Advantage plans to offer additional benefits, such as coverage for routine vision, dental care, and hearing services, and additional wellness benefits, such as gym memberships, over-the-counter medications, and more.
The comprehensive nature of the benefits provided under a Medicare Advantage plan may be attractive to those who want to make sure their healthcare plan covers a wide range of potential medical needs.
Managing your healthcare can be complex, particularly when different aspects of your healthcare needs are covered under separate plans. Medicare Advantage plans can help mitigate the confusion by consolidating coverage into one plan that may also have a single premium. This makes it easier to understand exactly what is covered and how much it costs without the stress that can come from managing multiple policies.
If there’s a problem with coverage or you have specific questions, it’s easier to have a single point of contact who can help you fully understand the details of your plan.
Potential Cost Savings
Despite potentially having higher out-of-pocket costs than Original Medicare, Medicare Advantage plans may still be more affordable for many individuals. This is mainly due to how Part C plans package benefits, offering a broad scope of healthcare services not included in Original Medicare.
When considering the total costs, including premiums, deductibles, copayments, and the value of additional benefits, some find Medicare Advantage plans to be a cost-effective alternative to Original Medicare, even when paired with Medigap and/or Part D coverage. Remember that cost-effectiveness can vary based on your personal circumstances, specific healthcare needs, and more, making it critical to carefully evaluate your options before making a decision.
Is Medicare Advantage Worth It?
While an analysis of potential pros and cons can leave your head spinning, many people believe that Medicare Advantage plans are worth it. The popularity of Medicare Advantage plans has been steadily rising. As of 2022, more than 28 million Medicare beneficiaries, nearly half of the total Medicare population, opted for Medicare Advantage over Original Medicare.
According to recent surveys, 98% of recipients who enrolled in Medicare Advantage plans reported being satisfied with their healthcare coverage, and 97% stated that they are satisfied with their network of physicians, specialists, and hospitals. Numerous medical journal studies have also concluded that Medicare Advantage delivers significantly better quality of care, lower costs, and improved health outcomes when compared to traditional Medicare. So, depending on your needs, even the “worst” Medicare Advantage plans may offer additional benefits over Original Medicare.
Again, while neither Original Medicare nor Medicare Advantage is inherently good or bad, some individuals may find a Medicare Advantage plan appropriate for their needs.
Who May Find Medicare Advantage Worth It?
In certain circumstances, the features and benefits of a Medicare Advantage plan may be more advantageous when compared to Original Medicare. This may be the case if you fall into one of the following categories:
- Individuals seeking comprehensive coverage: Medicare Advantage plans typically offer broader coverage than Original Medicare, including benefits like prescription drugs (Part D), vision, dental, and wellness programs.
- Beneficiaries prioritizing convenience: The all-in-one nature of Medicare Advantage plans means you may only have to deal with a single plan, potentially simplifying how you manage your healthcare needs.
- Cost-conscious individuals: Depending on your coverage needs, you may find that a Medicare Advantage plan is more cost effective due to the included extra benefits and out-of-pocket maximum.
Who May Find Medicare Advantage Not Worth It?
In some cases, the potential drawbacks of a Medicare Advantage plan may outweigh the benefits. If you fall into one of the following categories, a Part C plan may not be right for you:
- Frequent travelers or those planning to relocate: Network restrictions can disrupt coverage or lead to additional out-of-pocket costs when you receive services in locations that are outside the plan’s network.
- Patients with specific care requirements: If your preferred healthcare providers are not part of a Medicare Advantage plan network that is available to you, Original Medicare may be a better fit for your needs.
- Individuals needing consistent but low-cost care: If you need recurring care that does not meet your plan’s deductible, you could end up paying more in copayments than you might if you were covered by Original Medicare.
Putting It All Together
Deciding between Original Medicare and a Medicare Advantage plan requires careful consideration, and there’s no inherently “right” choice. Whether you find that a Medicare Advantage plan is worth it depends mainly on your individual needs and circumstances. For some, a Part C plan may provide more comprehensive coverage, all-in-one convenience, and potential cost savings. However, network restrictions, possible higher out-of-pocket costs, and overall complexity may deter you from choosing a Medicare Advantage plan.
When comparing your options, evaluating your healthcare requirements, financial situation, and lifestyle is essential. Ensure you understand the trade-offs involved in each choice and select an option that aligns with your personal health goals, financial capacity, and overall comfort with the plan’s offerings.