A Review of Medicare Advantage vs. Original Medicare and Medigap
One of the most common questions we get here at MedicareWire is, “are Medicare Advantage plans bad?” In this article, we will explore this exceptionally important question by contrasting Medicare Advantage plans vs. Original Medicare and Medigap.
- Medicare Advantage is not the best solution for everyone.
- With Medicare Advantage, most costs are paid when you use health care services.
- With Original Medicare and Medigap, most costs are paid in advance.
- In some circumstances, a Medicare Advantage plan helps people save money and get more coverage.
- Medicare Advantage plans are most beneficial if you are healthy and/or receive assistance paying shared costs.
- Where available, Medicare Advantage Special Needs Plans are affordable for those who qualify for both Medicare and Medicaid.
Why Do So Many People Feel Medicare Advantage is Bad?
In our experience, the question comes up because people ask their friends, neighbors, and healthcare providers about Medicare plans, and that brings up the horror stories and a litany of reasons why people dislike their plan.
But, is it true?
Over the years, we’ve heard from many people, healthcare providers in particular, that they dislike Medicare Advantage plans, but that does not mean they are bad.
These are the 7 most common reasons we’ve documented that make people feel Medicare Advantage plans are terrible:
- Free plans are not really free
- Hospitalization costs more, not less
- They make you pay multiple copays for the same issue
- You are more likely to see a nurse practitioner than a doctor
- They make you get a referral
- Plan benefits, costs, and providers change every year
- High maximum out-of-pocket limits
One of the best ways we’ve discovered to figure out if a Medicare Advantage plan is right for you is to compare them directly with Original Medicare and a Medigap plan. So, let’s do that by digging into the advantages and disadvantages of Medicare Advantage plans so we can figure out what is real and what isn’t, and help you find the best Medicare plan for you and your situation.
Only then can you decide if this Medicare coverage option is right for you. We’ll also answer these popular questions:
There is no debate when it comes to which plan offers better coverage. Original Medicare and a supplement plan offer the best coverage, but it costs more up-front. For a complete breakdown of the differences between Medicare Advantage plans and Medigap plans, read: Medicare Advantage vs Medigap: Which is Best for You?
The primary advantage is the monthly premium, which is generally lower than Medigap plans. The top disadvantages are that you must use provider networks and the copays can nickel and dime you to death. To discover all of the pros and cons of Medicare Advantage, read: What are the Advantages and Disadvantages of Medicare Advantage Plans?
MA Plan Pros
- The maximum out-of-pocket cost is $7,550 a year
- Many plans cost $0 extra a month
- Most plans include drug coverage
- Many include basic hearing, dental, and vision benefits
- May include gym discounts (Silver Sneakers)
MA Plan Cons
- Can only switch during Open Enrollment
- Not easy to compare because plans are not standardized
- No nationwide coverage (plans don't travel with you)
- Most are HMO plans that require referrals to see a specialist
- Plans can change health and drug coverage each year
Learn more in this article.
Some Medicare Advantage plans offer a zero-dollar monthly premium because what Medicare pays the plan, plus your Medicare Part B premium, cover the full cost. For healthy people who want to keep their monthly costs low, these plans are an attractive option. But, just be aware that the premium is not the only cost. Plans also have copays or coinsurance you must pay when you use services. To learn more about free Medicare Advantage plans, read Why are Some Medicare Advantage Plans Free?
Reason 1: Free Plans Are Not Really Free
This is true.
The real issue here is people’s misunderstanding of how Medicare Advantage plans (aka, MA plans or Medicare Part C) work. Specifically, many people don’t understand co-payments (copays) and coinsurance. So, if you are wondering, “how can Medicare Advantage plans be free?”, they aren’t. Far from it.
Just like Original Medicare (Part A and Part B), Medicare Advantage is a cost-sharing system. With Original Medicare beneficiaries pay about 20 percent of the cost for all Medicare-approved services and Medicare pays 80 percent. With a Medicare Advantage plan, you also pay about 20 percent of your costs, but there is an annual cap that limits your out-of-pocket costs.
NOTE: The annual maximum out-of-pocket (MOOP) limit that’s built into all Medicare Advantage plans is a major advantage. For those beneficiaries with chronic health conditions, who cannot get a Medicare supplement, the annual MOOP keeps them out of bankruptcy from excessive medical bills.
ALSO: Some zero-dollar premium Medicare Advantage plans can rebate all or a portion of your Medicare Part B premium ($148.50 in 2021) back to members as part of their monthly Social Security check. In other words, the Medicare Advantage plan pays your Part B premium for you.
Reason 2: Hospitalization Costs More, Not Less
In many cases and with many plans, this is true.
In fact, a recent Kaiser Family Foundation study shows that half of all Medicare Advantage enrollees would incur higher costs than beneficiaries in traditional Medicare for a 5-day hospital stay. That’s shocking, but given the rising cost of hospitalization, it’s also understandable.
This fact also underscores the need to carefully scrutinize Medicare Advantage plans annually so you are not surprised by the bills. Ambulance, emergency room, diagnostic, hospitalization, and inpatient medication copays add up very fast.
IMPORTANT: If you are getting your Medicare benefits for the first time, and you have a chronic health condition that necessitates frequent care, pay careful attention to Medicare Advantage hospitalization costs. If you can get a Medicare supplement during your guaranteed-issue period, your hospitalization costs over time will generally be lower.
Reason 3: They Make You Pay Multiple Copays For The Same Issue
This is true, but it is also true with Original Medicare. However, this complaint highlights the chief difference between Medicare Advantage and Original Medicare plus a Medicare supplement.
Medicare Advantage is a pay-as-you-go system. You pay your monthly Medicare Part B premium, and an additional premium for the plan (if any), but the majority of your costs come when you use healthcare services. So, if you see your primary care doctor for an issue you pay a copay. If your doctor refers you to a specialist you pay another copay. And if your specialist orders lab tests or diagnostic tests you pay a copay for each of those, as well.
If you have Original Medicare and a Medigap Plan G supplement, you pay your monthly Medicare Part B and supplement premiums, but pay virtually nothing when you use healthcare services once the annual Part B premium is paid. This includes Medicare Part B Excess Charges if your doctor does not accept Medicare’s standard rates. Understanding this fundamental financial difference is the key to getting the best insurance for your personal situation.
Reason 4: You Are More Likely To See A Nurse Practitioner Than A Doctor
In many cases this is true. HMO and PPO health plans (most Medicare Advantage plans are HMOs) use a method called capitation to pay providers. A capitated contract pays a provider in the plan’s network a flat fee for each patient it covers. Under a capitated contract, an HMO or managed care organization pays a fixed amount of money for its members to the health care provider.
For this reason, many primary care group practices use nurse practitioners and aides to reduce their costs so they can see as many patients as possible. These healthcare workers are supervised by a physician.
Reason 5: They Make You Get A Referral
In the case of HMO plans and some PPO plans, this is true. According to the Kaiser Family Foundation, nearly all Medicare Advantage plan enrollees are in plans that require prior authorization for some services. Health plans are in the business of making money and this is one of the primary ways they have to control costs.
By the way, Congress implemented a similar cost-saving measure with Medicare supplement insurance. As of 1 January 2020, new Medicare beneficiaries cannot buy a Medigap plan that covers the Part B deductible. The hope is that this change will reduce unnecessary doctor visits.
Reason 6: Plan Benefits, Costs, and Providers Change Every Year
This is true. Under the rules set out by the Centers for Medicare and Medicaid Services (CMS), insurers may change the benefits and costs in their plans. They are also allowed to change their provider networks.
This is the primary reason Medicare Advantage members should compare plans every year. Unfortunately, most enrollees don’t.
Reason 7: High Maximum Out-of-Pocket Limits
This is true. For 2020 Medicare Advantage enrollees, the average out-of-pocket limit was $4,925 for in-network services. For PPOs, the average is $8,828 for both in-network and out-of-network services (PPOs). These figures are expected to increase for 2021 and beyond. The future increase is reflected in the new maximum out-of-pocket limit set by CMS, which increased from $6,700 to $7,550.
NOTE: High-deductible Medicare supplements, and shared-cost plans, like Medigap Plan K, may also have high out-of-pocket limits. However, no Medicare supplements are as high as the current $7,550 MOOP limit with Medicare Advantage.
Are Medicare Advantage Plans Really Bad?
The only way to determine if a Medicare Advantage plan is right for you is to take time to understand plan costs and limitations and balance that with your healthcare needs. When you do this you will discover:
- If You Are Healthy – A Medicare Advantage plan is a great way to save money if you are healthy. If you take advantage of the preventative care benefits, and additional benefits, you will get a lot for your money.
- If You Have Employer Health Benefits – Many employers offer workers and retirees health benefits that pay their Medicare Advantage plan premiums and other costs. If you have employer benefits, it’s a great way to save money.
- If You Qualify for Medicare and Medicaid – Nearly 3-million people have a Medicare Advantage Special Needs Plan (SNP). The majority of these people qualify for an SNP for financial reasons and pay minimal copays and coinsurance costs when they use services. If you can qualify, and an SNP is available in your county, it is the best way to get your healthcare.
- If You Are a Veteran and Have VA Health Benefits – Veterans with VA health benefits can be enrolled in both Medicare and VA Healthcare at the same time. When they are, Medicare is the primary payor and the VA is secondary. When receiving care at a VA facility, the veteran generally pays nothing. This holds true when receiving care at a non-VA facility if the veteran receives prior approval.
- If You Have Chronic Health Conditions – People with chronic health issues, who do not have employer, Medicaid, or VA health benefits may find that Medicare Advantage is unaffordable for them. This is particularly true if their health condition frequently puts them in the hospital for emergency care, or necessitates the regular use of specialists. Many diabetics fall into this category. For these people, Original Medicare and a Medigap plan are generally more cost-effective, particularly if the supplement is purchased when the beneficiary turns age 65 and has guaranteed issue rights.
The Disadvantage of Medicare Advantage Plans
In Understanding Medicare in 4 Easy Steps, we outline how to determine if Medicare Advantage or Original Medicare and a Medigap plan is the best option for you. To paraphrase, I suggest that there’s a single fundamental difference that helps most people make the right choice. In fact, the bulk of the pros and cons of Medicare Advantage plans take a back seat to this one issue.
The difference is this. With Original Medicare and supplemental Medicare insurance, you pay the bulk of your major medical costs upfront through monthly insurance premiums. Doing so lets you budget your health care costs.
When you have Medicare Advantage, you pay most of your health care costs when you use services. For this reason, it is very difficult to budget your health care costs. And this is the primary disadvantage of Medicare Advantage plans. If you fit into one of the five categories above, this won’t be much of a disadvantage. If not, it could put you in a world of hurt.
Is It Better to Have Medicare Advantage or Medigap?
We’re often asked which is best, Original Medicare or Medicare Advantage? The issue really comes down to peace of mind. You don’t need supplemental insurance with Medicare Advantage. However, with Original Medicare, you can get supplemental insurance to fill the gaps.
If you have access to additional benefits (e.g., employer, Medicaid, VA) that will take care of some or all of your out-of-pocket costs, use those benefits. If not, ask yourself if you are prepared to pay up to the maximum out-of-pocket limit on a Medicare Advantage plan.
When it comes to which is better, Medigap or Medicare Advantage, consider this. If the prospect of pulling an average of $4,925 out of your pocket, which does not include your prescriptions or monthly premiums, makes you nervous, then it’s time to compare the top Medigap plans in your area. When you do, you will find a wide range of coverage options.
If you are a healthy senior, Medigap Plan N is a great way to save money and get the peace of mind most of us need when it comes to our health. Even a Medigap Plan K, which some experts feel has high out-of-pocket costs, can be a better option if you use a lot of medical and healthcare services.
What is Medigap?
We’ve mentioned Medigap a few times in this article. If you’re not familiar with the term, or how it can help, here’s a quick overview.
Medigap is Medicare’s terminology for supplemental Medicare insurance. Unlike Medicare Advantage, when you get a Medigap plan you do not give up your Original Medicare benefits.
Medigap, as the name implies, fills the gaps in Original Medicare. By this, we mean the Medicare beneficiary’s out-of-pocket expenses from the various Medicare Part A and Part B deductibles and coinsurance. It is easy to see what these costs are, and which Medigap plans cover them by looking at a Medicare supplement plans comparison chart:
With Medigap, there are ten standardized plans (A, B, C, D, F, G, K, L, M, and N). Regardless of which insurance company you get a plan from, its benefits and coverage are the same. Only the monthly premium is different.
With Medicare Advantage plans, your costs and coverage aren’t as clear-cut. That’s one of the top reasons people feel Medigap is better than Medicare Advantage.
Original Medicare vs. Medicare Advantage: How Private Insurance Company Plans Work
Medicare Advantage plans are provided by private health insurance companies and group healthcare providers whereas Original Medicare coverage comes from the federal government’s Medicare program.
The reason private plans seem to be so inexpensive, compared to a regular HMO (health maintenance organization) or PPO (preferred provider organization) health plans is that the federal Medicare program pays the plan you choose for your care.
When you join a private health plan, Medicare pays the plan $750 per month or more to take over your hospital and medical care costs (i.e., Medicare Part A and B). Add to that your monthly Part B premium (in most cases subtracted from your Social Security income), plus any additional monthly premium the plan charges, and you’ll get an idea of the true cost.
An important thing to understand about a Medicare Advantage plan is that, while enrolled, you no longer have your Original Medicare benefits. The insurance company behind your plan provides your benefits and makes up its own rules. They must follow Medicare’s guidelines, but those guidelines are very broad and leave a lot of room for interpretation. This often leads to a good deal of frustration about what’s cover, what isn’t covered, how much you’ll pay out of pocket, and getting prior approval for coverage.
Please go back and read the bullet points in the sections above. If you are healthy, your frustrations will likely be few. If you have one or more chronic health conditions, your frustration could be many and frequent based on your plan’s pre-approval process and copays.
The good side of Medicare Advantage is that insurance companies are generally obligated to sell you a policy, regardless of any preexisting conditions. This is contrary to Medicare supplement insurance, where the insurance carrier is almost completely in control of policy approval or denial through their Medicare underwriting process. So, if you have been denied Medigap insurance, Medicare Advantage is almost always a better option than Original Medicare alone.
Pros and Cons of Medicare Advantage Plans vs. Original Medicare
In addition to the fact that Medicare Advantage plan insurance carriers are generally obligated to sell you a plan, they also bundle additional benefits, such as vision, dental, hearing, and a prescription drug plan (Part D). These are valuable benefits that Original Medicare does not cover.
Many of the extra benefits that some insurance plans offer look very enticing, but they often come with limits or high out-of-pocket costs. For example, a plan may have excellent healthcare benefits (i.e., low copays) and a poor Part D plan (i.e., your meds are not covered in the lower tiers).
Also, it is important to understand that the extra benefits, including Part D prescriptions, are not included in the plan’s maximum out-of-pocket (MOOP) limit. So, let’s say you use the plan’s dental coverage and pay $1,500 in copays for restoration work, that $1,500 is not included in your MOOP, nor are your Part D medications. This is why so many people feel that traditional Medicare, plus a supplement plan, dental plan, and a stand-alone Medicare Part D plan are the best way to go.
What is the Best Medicare Advantage Plan?
If you’ve read this far, you’re probably wondering which Medicare Advantage plan is the best. Is it Humana, AARP, Aetna, Blue Cross Blue Shield, Cigna, Wellcare, or Kaiser?
It’s easy to answer the question, “What is the best Medicare supplement insurance plan?” It’s Plan F. It offers the most coverage.
We wish the answer was as clear-cut with Medicare Advantage, but it’s not. Here’s why.
When you combine all of the standard Medicare Advantage plans, employer plans, and Special Needs Plans, there are literally over 70,000 plan options. It’s a truly staggering number.
The good news is that all of those plans are organized across nearly 2,800 U.S. counties. Why? Because most plans use local provider networks, making county boundaries the most logical way to organize private health insurance.
To find the best private health plan for you, use our Plan Finder tool. It will show you all of the plans in your area, their 5-star rating, premiums, copayments, and extra benefits, too. If you have both Medicare and Medicaid, use the SNP Plan Finder. Plus, every plan page has a free PDF document you can download with basic cost and coverage information.
What are the Worst Medicare Advantage Plans?
The Centers for Medicare & Medicaid Services does an excellent job of weeding out bad Medicare Advantage plans. Sub-par plans are given a year to clean up their act and CMS sanctions them.
So, what is a bad plan?
Generally, plans get sanctioned for bad customer service, poor performance managing chronic health conditions, a bad track record keeping members healthy (screenings, tests, vaccines, etc.), and a poor member experience with the drug plan (if included). All of these measures are graded by CMS annually, and more. You can check each of the ten grades a health plan receives on our plan pages.
Beyond the 5-star grades, you must look at how a plan will cover you. By this, we mean the out-of-pocket costs you will be charged by the plan when you use health care services. A 4- or 5-star plan can be fantastic for one member and the worst of the bunch for another. It all depends on your total costs.
You must do the research and run numbers based on how you expect to use a plan’s benefits. Only then will you know if the plan you are choosing is a winner or a loser.
Medicare Advantage Enrollment
Unlike supplemental Medicare insurance, you can’t enroll in Medicare Advantage year-round. There are specific enrollment periods for enrolling in an Advantage plan. The same is true if you want to switch plans.
For most people, there are two dates to remember. The first is your Initial Coverage Election Period (ICEP). This occurs when you are first eligible for Medicare, generally on your 65th birthday or 24 months after you first qualify for Social Security disability income. Your ICEP is a seven-month window of time that begins three months prior to your birth month and ends three months after your birth month. The second date is the Annual Election Period in the Fall, which starts 15 October and ends 7 December.
Eligibility for the Initial Coverage Election Period
To sign up for a Medicare Advantage plan:
- You must have both Medicare Part A and Part B;
- You must permanently reside in the service area of the plan; and
- In most cases, you can’t have end-stage renal disease (ESRD).
Most commonly, you’re eligible for Medicare Part A and Part B:
- At age 65.
- As of your 25th month of disability benefits.
- As of the first month that you start receiving disability benefits based on amyotrophic lateral sclerosis (ALS).
If you are electing to join a Special Needs Plan, you will have other eligibility criteria. A Special Needs Plan is a special type of Medicare Advantage plan for people with certain financial or healthcare needs.
Medicare Annual Election Period
The Medicare Advantage Annual Election Period (AEP), also called Medicare Open Enrollment, is the period when beneficiaries can enroll in a Medicare Advantage plan, switch plans, add prescription drug coverage, or disenroll from a Medicare Advantage plan and return to Original Medicare. It occurs every Fall from October 15 to December 7. You’ll know it’s coming up when you start seeing Medicare commercials on TV.
Do you still have questions? Call 855-266-4865 and chat with a Medicare insurance advisor.
Citations & References:
- Medicare Advantage Plans | Medicare
- What’s Medicare Supplement Insurance (Medigap)? | Medicare
- Find Healthcare Providers: Compare Care Near You | Medicare
- Home | State Health Insurance Assistance Programs
- 2020 Medicare Parts A & B Premiums and Deductibles | CMS
- Trump Administration Announces Historically Low Premiums and New Insulin Bene…
- Institutional Special Needs Plans (I-SNPs) | CMS
- A Dozen Facts About Medicare Advantage in 2020 | KFF
- A Dozen Facts About Medicare Advantage in 2019 | KFF
- Medicare Advantage | KFF
- Getting Medicare right. – Medicare Rights Center