Medicare Advantage Plans Not Always the Best Option

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Medicare Advantage Plans

Medicare Advantage Plans have many limitations including controlling which health care provider a beneficiary can use.

 The Medicare Rights Center cites the most common problems associated with Medicare Advantage Plans.


Medicare Advantage Plans (also called Medicare private health plans) make up Part C of the Medicare health benefit. A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide a senior with all of their Part A and Part B benefits. Basically it’s an alternative way of receiving benefits. These plans primarily include HMOs, PPOs, and Private Fee-for-Service plans.

The plans may look good on the surface because they offer the same basic coverage as Original Medicare, plus some additional benefits and services that Original Medicare doesn’t cover. However, when compared with what is included in Original Medicare, the Medicare Advantage Plans prove to have many limitations and often fall short of delivering the best care at the right price. In fact, they aren’t nearly as advantageous as having Medicare Parts A and B alone – much less with the optional Part D prescription coverage and Medigap supplemental insurance that a beneficiary can get only with Original Medicare.

Although the idea behind Medicare Advantage Plans is to provide better services and lower out-of-pocket costs, it doesn’t always work that way, according to the Medicare Rights Center. While Medicare Advantage Plans must provide a benefit “package” that is at least as good as original Medicare’s and cover everything Medicare covers, the plans do not have to cover every benefit in the same way. For example, plans may pay less for some benefits, like skilled nursing facility care, and offset this by offering lower copayments for doctor visits.

A major concern with Medicare Advantage Plans is that they control what health care provider a beneficiary can use. Under a Medicare Advantage Plan, if a patient has cancer, they will be referred to a cancer doctor in the plan, but if there is a cancer doctor that a patient really wants to see and this doctor is not in their plan’s specific network, they most likely won’t be able to see that doctor. And if they do decide to see that doctor anyway, they won’t have Medicare Parts A and B to fall back on, so they will have to pay for all of those costs on their own.

Another drawback to Medicare Advantage Plans is that they place administrative restrictions on physicians for claim payments and referrals, which may ultimately compromise the treatment a patient receives.

Here is a list of the most common problems associated with Medicare Advantage Plans, according to the Medicare Rights Center:

  • Care can cost more than it would under original Medicare.
  • Private plans are not stable and may suddenly cease coverage.
  • Members may experience difficulty getting emergency or urgent care.
  • Because plans only cover certain doctors, the continuity of care is often broken when the plan drops a provider.
  • Members have to follow plan rules to get covered care.
  • Members are restricted in their choices of doctors, hospitals, and other providers.
  • It can be difficult to get care away from home.
  • The extra benefits offered often turn out to be less than promised.
  • People with both Medicare and Medicaid can encounter higher costs.