Medicare Advantage is an alternative to original Medicare. The name is disturbingly misleading. It isn’t actually Medicare, and often getting it puts the client at a disadvantage.
What do I mean? Well, Medicare Advantage Plans are really private insurance plans that replace original Medicare. They do not need to follow Medicare’s rules and while aspects of how they work are supposed to make it equivalent to Medicare, that definitely isn’t always the case.
Medicare Advantage is also referred to as Medicare part C, and all the official material talks about how it offers additional coverage to Medicare, and is used as a substitute for Medicare parts B(medical care) and Medicare part D(medication).
Much like selecting a private insurance plan, the results will vary widely. In way too many cases, switching to a Medicare Advantage program isn’t worth it.
Do not be fooled by their boasted “extras”, Medicare Advantage is generally a program that provides less support to you as a patient, and substantially limits your treatment options.
Most Medicare Advantage programs provide cards that replace your Medicare card, and work much more like an HMO than Medicare. There are exceptions that function as other types of plans(like EPOs or even PPOs), but you need to read the details of the plans very carefully to ensure this. Remember that Original Medicare is a PPO, which tends to give you the most options in terms of who is treating you.
Often, there is a much smaller field of options for treatment(in-network providers), and in many cases, you simply can’t go out of network(again, there are exceptions, but you need to search for them).
If you can go out of network, you are absolutely paying a premium for that option. While Original Medicare also only allows you to see in-network providers, they have one of, if not the, largest provider networks in the country.
These programs also control your medication costs and payments, and again, they are often more limiting than many of the Medicare drug plans.
I was fooled into joining a Medicare Advantage plan, not once, but twice, and am now extremely leery of them.
How I was tricked into Medicare Advantage while on Medicaid(and Medicare)
The first time, I was dual-eligible, and “original Medicaid” was no longer an option in NJ, so I was forced to select one of 5 HMOs.
I got a phone call from the provider for my Medicaid HMO, telling me about how I could improve my coverage by bundling it into the Medicare Advantage program.
They told me about the “silver sneakers” gym membership available in many gyms near me(free or reduced-cost memberships), the dental coverage, and the vision coverage.
I fell for it.
When my plan was changed, I received my replacement card, and discovered that only one or two of my doctors worked with the plan.
All of them worked with Medicare – I was probably seeing five or so medical professionals at the time, and with the new plan I had copays for every appointment when with Original Medicare I only was billed at all for two or three appointments
My medications were also more expensive, with a copay based upon their plan, rather than Medicaid(which fully covered many of my medications).
When I called to cancel it, they informed me that I had to fax them a signed form confirming that I wanted to return to original Medicare. This felt a bit rich, considering that their company had called me, encouraged me to use their plan, and then accepted my vocal agreement as proof that I had agreed to switch plans.
It took me the rest of the month to get out of the plan.
I was only able to exit it that quickly because one of the benefits of having both Medicare and Medicaid is that you can switch between plans at any time, rather than only during the open enrollment period.
I canceled appointments and had to hunker down and wait until I returned to my normal Medicare program.
I swore to myself that I would never again try a Medicare Advantage program.
Comparing costs
Original Medicare is relatively inexpensive, $164.90/month for part B(unless your income is over 97,000) and generally $30-150/month for part D(depending on your medication coverage needs).
Medicare Advantage(private insurance) boasts about having no monthly charges(sometimes they don’t), but you often may end up spending a lot more money to pay for your appointments and treatment.
Original Medicare covers 80% of your costs, while some of the “advantage” plans say they cover more(“only copays for in-network doctors” and similar statements.) – but what they don’t mention is that not only are your options more limited, you do now have copays, which are always required and are often more than the residual amount you pay for that remaining 20%.
For example, when I see my neurologists, I get a bill for residual costs each time – it’s usually about $25, while the original bill is close to $250. Medicare reduced the original bill through negotiations with that medical service, then I pay only 20% of that reduced cost.
If I was on an “Advantage” plan, and they covered my neurologist(a big if) I’d need to pay the copay when I walked into the appointment(copays often range from $10-$40), and if anything in the appointment wasn’t covered(they often don’t cover everything Medicare does), I may have to pay for that as well.
I would be pulling money from my pocket immediately and while the initial price is stated, there’s always a possibility of bills afterward as well.
This is one of the ways “Medicare Advantage” guarantees more money in their pockets.
On top of that, many Medicare Advantage programs often require that you get a referral for each specialist you see, which means more appointments with your Primary Care Physician(PCP)(who also MUST be in-network or it doesn’t count), and more copays for you to pay.
To see my neurologist, I’d need to have to see my PCP to get the referral(paying the copay), and then see my neurologist. Original Medicare doesn’t even require that you have a PCP, and you never need a referral.
Also, I’d be much less likely to be able to see my neurologist because any of the Advantage plans has more limited options than original Medicare, as fewer doctors participate in their programs.
Every drug plan has its own list(called a formulary) of eligible medications, copay costs, and monthly plan costs.
Most Medicare Advantage programs have their own drug plan. If a medication isn’t covered, you pay full price for it.
If it is covered, the plan charges you whatever amount is in the formulary, and sometimes charges an additional copay.
Generally, Medicare Advantage programs have higher copays and/or more expensive drug costs for many medications. That’s another way the program gets their money back.
Every year, the formulary for every plan changes slightly, so to keep your medications at the lowest possible rate, it behooves you to check every year, and compare costs and values.
Also, some medications are categorized on different tiers, which often controls how much the copay is.
Again, there are some Medicare Advantage plans that do offer reasonable coverage, good options, and/or reasonable formularies that cover your medications. It’s just that these are not necessarily easy to dig out of the mass of plans that are intended to take advantage of you. If you are ready to dig deeply into the mess and carefully examine your options, you may very well find a plan that better fits your needs.
Just be aware that if you don’t check carefully, you may have a plan that is a worse option for you than original Medicare would have been.
How did I get tricked?
So, in 2019, I unintentionally signed up for a Medicare Advantage Plan because those precise words weren’t used.
I called Walgreen’s Medicare plan selection line(learn from me: only discuss your plan options with an organization that doesn’t get a commission or other benefit based on what plan you choose)
On that call, I discussed my part D options. The woman I talked to brought up the additional plan options and wanted to know if I wanted to use that since I no longer had Medicaid.
I allowed her to look into them, and I asked a lot of coverage questions, which she gave me reasonable answers to.
I also very specifically asked about networks and limitations on visits, and she blithely informed me that if their plan didn’t cover something, I could also use my Medicare card(making it sound like I didn’t lose any options.)
It sounded a little off, but she swore that that was how it worked.
I believed her and agreed to switch to the plan she was pushing.
A few days later, I talked to the scheduler at my PT’s office, and she checked into it and told me that they were out of network and that I couldn’t do as the woman had suggested.
I called back and was able to speak to a different employee and have my plan changed back to original Medicare, but it took several calls and was much more difficult to do than the original switch was.
If I hadn’t stopped the plan then, I would have been stuck with it for a year, and wouldn’t have been able to see my pelvic floor physical therapist or several of my other doctors.
I do not know if the woman I talked to was intentionally lying to trick me into the other program, or if she didn’t understand how it worked and unintentionally gave me bad information.
Either way, though, the effect was pretty unfortunate, and I had a lot of extra stress to manage that winter than I should have.
In January, I had to call the Medicare Advantage program again because they hadn’t gotten the message that I’d disenrolled.
I had to call them multiple times (each time, even calling the number on the back of the card, I was shunted around to multiple people) to get them to understand that I wasn’t on their plan.
I think it’s very important to be aware of these plans, and their dangers, because it is so easy to be misled into signing up, or do so without understanding the consequences of the decision.
The Medicare Advantage programs are often HMOs and much more limiting than original Medicare.
They also have a much larger advertising budget(since they are private health insurance providers) than original Medicare(a government program) and tend to be more comfortable making dubious claims.
If you receive an advertisement for a Medicare Advantage Plan, view it with skepticism. If they feel the need to send out flyers, postcards, and other forms of advertisement to Medicare recipients, that may be an indicator of their desire for more clients, often a sign that they don’t have great retention.
Making sure you’re on the right program
Medicare Advantage is also referred to as “Medicare Part C”. Original Medicare is parts A(hospital), B(medical professionals), and D(medications).
Medicare A is effectively free, and it covers hospital usage. For Medicare B, you should be billed monthly(this can be taken out of your check every month before you get it, or you can elect to mail it in every month), and part D is what you use at the pharmacy to get your medications.
This part D coverage is required, and you are billed separately for it(prices can start under $30, and most are under $100).
The drug plans are generally not run by the insurance companies you may be used to hearing about. I’ve used AARP, Wellcare, Silverscript, and others. The larger medical plans(like Aetna, Blue Cross Blue Shield, etc) seem to now own many of these companies and have part D plans of their own as well.
I’m currently using a Blue Cross Blue Shield plan due to needing to try new migraine medications.
The big-name insurance companies seem to get deeper into Medicare part D every year. While some of the less-common names are still out there, many plans now belong to the same few companies that offer private insurance. They will have quite a few plan options, and often the difference between their options will be difficult to discern beyond the obvious difference in monthly cost. Dig into it, and use your drug list to help you pick the plan that will work best for you.
The important thing is finding a plan that will give you the best possible rate for the medications you are and may be taking for the year.
You want to have both Medicare Part B(which combined with part A is Original Medicare), and your Medicare part D(drug plan), together.
If you choose Advantage Plan (part C) it replaces both part B and part D, and the name usually contains a specific large insurance company(such as Aetna, Blue cross/blue shield, or United Health care).
When you search for your part D plan, you may see a banner or other announcement of “similar” or “cheaper” options. Do not click on that, as that’s often another way to include those Medicare Advantage plans to your options.
Medicare Advantage can benefit you, if you’re careful
I have spoken to a few other disabled people who swear by their Medicare Advantage Program.
The conversations I most remember are with folks who did the very careful digging to find Advantage Programs that did allow for out-of-network supports had larger networks and generally operated similarly to a quality private insurance provider. If you can, you want to avoid HMOs, which many, but definitely not all, Advantage Plans are.
The folks I talked to also had a lot of medical expenses that were covered by their advantage plans. They felt that their copayments or coinsurance costs were less than the 20% charges associated with Original Medicare.
Medicare Advantage also provides some dental and vision coverage, as well as possibly gym membership and minimal fees. Those can have value, especially if you need more than the average amount of dental or vision care.
Read over the advantages they list very carefully before committing to the program, but if it really is a better deal for you, it may be alright.
If you want to compare Medicare Advantage to your current plan, you will want to ask about costs associated with out-of-network doctors, and check all of your current doctors against their list of in-network providers, then double-check with your doctors to confirm that they accept the plan.
Too many insurance plans neglect to remove doctors who no longer work with them from their lists.
You also will want an estimate for your monthly medication cost – which you can get by having them look up your medications on the Advantage plan you are looking into.
If all your doctors are covered and all your medications are at a similar or lower cost per month(including the monthly fee for participating), it may make sense to choose a Medicare Advantage program.
You will also want to double-check that any procedures you normally have will be covered if you’re anticipating something. Medicare Advantage programs do NOT follow the same rules as Medicare, so proceed with caution!
Medicare also has now adjusted a rule to reduce your risks with Medicare Advantage Plans.
If you select a Medicare Advantage Plan and are dissatisfied with it, you can change your plan – once and only once – between January and March.
This means that if you feel misled by the plan that you selected, you may switch back to Original Medicare(and select a new Part D plan to replace your Advantage Plan) or switch back to the Medicare Advantage plan you previously felt was a good fit.
The downside, of course, is that whatever you paid during that time is still owed, and the money spent will not be considered towards the deductible of the new plan you start using.
I think it speaks volumes that this option now exists since the Medicare administration isn’t very flexible or communicative generally. To be clear, I think this speaks volumes on just how limiting some of the Medicare Advantage Programs are.
Help yourself make the best choice each year
You can visit Medicare’s website and create your own account, then list your medications and have the system check your formulary options.
There are often ways to make things slightly less expensive if you plan ahead(such as having medication mailed to you or filling multiple months at a time) and if you can afford to(usually this means paying for three months at a time instead of one), but your best bet is to select your plan assuming you’ll be picking up your prescriptions monthly at a pharmacy.
Different drug plans prefer different pharmacies, so the cost of filling your prescription will be lower if you use their preferred chain or the individual pharmacies that have chosen to participate with their program.
If you know you only can easily access a particular pharmacy, look for plans that work with them – if you have more pharmacy options, make sure that you are using the pharmacy that can give you the best value.
Your other major considerations are your monthly fees, your deductible(how much money you need to pay before they help), the cost of your medication through their program, and how likely your prescriptions are to change over the year.
Some plans are more flexible than others, so if you and your doctor expect to experiment with your medications, it’s important to use a more flexible plan, where if you have several prescriptions that have really been working for you and your regimen is very stable, it may not matter how many options they have, as long as your prescription is one of them.
Select the plan that gives you the flexibility you need, and the lowest monthly cost(including the monthly cost of the plan) you can find.
If it all feels crazy confusing, focus on just a few of these aspects, the ones most important to you.
There are also volunteers trained to help you with your Medicare decisions through the State Health Insurance Plan(SHIP).
When my neurologist and I looked into migraine treatment options, I was pretty shocked by how expensive most migraine treatments were, and I know that those are nowhere near the most expensive medications out there.
The more medications, and especially more expensive medications you take, the more important it is for you to find the best possible drug plan!
My migraines were mild and infrequent enough that I was okay with minimal medication, but I definitely went through sticker shock when I developed migraines- and the cost of those pills were by far the most significantly varied. Once my migraine became constant in mid-2019, I jumped to a much more expensive plan so I could afford migraine medications that might work for me.
I am now paying over $100/month for my plan(that $30/month coverage in 2018 through AARP feels dreamily inexpensive), and paying much more per month as well than I did previously.
Conclusion: protect yourself by being sure you are on the best plan for you!
Because Medicare Advantage has these dubious qualities and focuses on the positives, it’s really important that you understand what you are committing to when you select your healthcare plan.
If you are Medicare-eligible, you should have a medicare card(which finally no longer uses social security numbers as identification numbers!!), and on it, it will say when and if you are eligible for Medicare parts A and B.
Every year, the details of all the drug plans(part D) will change, and you will select what plan works best for you. The list of medications and medication cost is referred to as the “formulary” and there are a lot of plans.
Medicare part C(Medicare Advantage) plans replace Medicare B and D, as well as providing dental and vision coverage and sometimes membership to Silver Sneakers, a fitness program.
Many Medicare Advantage programs are HMOs which greatly limit your options for care. While they are not all as limiting, selecting Medicare Advantage Plans should be approached cautiously as frequently the opportunity costs far outweigh the savings they offer.
