Medicare Advantage Plans: Read the Fine Print

Medicare open enrollment for 2021 ends on December 7th. No doubt, like me, you have seen the countless commercials and even 30-minute-long infomercials from various Medicare Advantage plans touting the great benefits of these plans—like dental and vision coverage, gym memberships, transportation to medical appointments—and many others.

For some, Medicare Advantage plans are good enough. But, if you have cancer or any other complex illness that necessitates frequent usage of healthcare services, these plans (honestly-like all insurance plans) have disadvantages. You are not going to hear about these disadvantages in those infomercials. 

What is a Medicare Advantage Plan?

  • Medicare Advantage plans are also referred to as Medicare Part C. 
  • If you are eligible for and have Medicare A and B coverage, you can enroll in a Medicare Advantage plan. 
  • These plans are offered and managed by third party insurance companies that have been approved by the Center for Medicare Services (CMS) to offer Medicare Advantage plans.
  • When you enroll in a Medicare Advantage plan you are essentially selling your traditional Medicare coverage to a private insurance company.
  • During open enrollment, you cannot switch back from Medicare Advantage to “regular” Medicare. You can only do this during the annual Medicare Advantage Disenrollment Period Jan 1st-March 31st.
  • During open enrollment you can switch from one Medicare Advantage plan to another. It is important to compare plans EVERY year during open enrollment.

What are the Key Differences Between Traditional Medicare and Medicare Advantage Plans?

Traditional MedicareMedicare Advantage
Medicare is a traditional fee-for-service insurance plan. Your provider bills Medicare for services.Medicare Advantage plans are typically HMOs or PPOs. Your provider bills Medicare for services.
You do not need a primary care physician/provider. You may need to have a primary care physician/provider who is the gatekeeper for all of your healthcare needs.  Some plans do not require a PCP. 
There is no office visit copay due the day you see a provider. You will be billed for your co-insurance (20%).There are office visit copays due the day you see your provider. These copays are typically higher for specialists and must be paid at every visit.
You do not need to get referrals to see specialists.You will need referrals/prior-authorization for specialty care and some services-this includes oncologists, radiation oncologists, labs, and radiology tests.
You can go to any healthcare provider that accepts Medicare.There is a preferred network of providers/facilities contracted with the plan. Going to an out of network provider could cost you a lot more. Your network providers may be more concentrated in the geographic area where you live. Keep this in mind if you are traveling–for vacation or maybe to an out of area specialist.
Your co-insurance for Part B (outpatient care) covered services is 20%. This means you are responsible for 20% of the costs of your care. This is a GAP in coverage.Your co-insurance for Part B (outpatient care) covered services is 20%. This means you are responsible for 20% of the costs of your care. This is a GAP in coverage.
There is no annual maximum out of pocket.There is an annual out of pocket maximum; it cannot be more than $7500 in-network and a combined $10,000 in and out of network. This resets annually-every January.
You can purchase a Medigap plan (also called supplemental) to cover your out of pocket costs.You CANNOT purchase a Medigap plan (also called supplemental) to cover your out of pocket costs.
Does not cover dental, vision, non-ambulance medical transportation, gym memberships or other special benefits.May offer dental, vision, non-ambulance medical transportation, gym memberships or other special benefits. This varies for each plan.
You must purchase a separate plan for Medicare Part D (prescription drug) coverage.Some plans include Medicare Part D prescription drug coverage. You may still need to pay a separate premium for part D coverage and the deductible, copay/co-insurance is separate from your major medical costs.May offer dental, vision, non-ambulance medical transportation, gym memberships or other special benefits. This varies for each plan.

What are the Takeaways in this Comparison?

  • You have to DO THE MATH. Compare the prices of Medigap (supplemental) plans available in your area with that out of pocket maximum you are responsible for with a Medicare Advantage plan.
    • For example, a Medigap plan with a premium of $300 per month will cost you $3600 per year and cover most of your out of pocket expenses as long as the provider is a Medicare provider. Whereas with an Advantage plan, you are on the hook for up to $7500 in-network and potentially up to $10,000 for out-of-network care. 
  • Your office visit co-pays, co-insurances, and any plan deductibles for Medicare Advantage plans count toward that out of pocket maximum. However, your DRUG costs DO NOT. They have separate deductibles and co-pays for prescription drugs.
  • Specialist co-pays can be much higher with Medicare Advantage plans. You also may have to get all of your labs and radiology exams performed as dedicated (called “capitated”) facilities-not necessarily where your provider is.
  • What are your potential out of pocket costs for things like vision and dental? 
  • Do gyms in your area already offer senior discount plans?
  • When you enroll in a plan matters – especially for Medigap plans. If you enroll outside of your initial enrollment period, these plans can look at your pre-existing conditions and charge you more for your premiums or even deny coverage. In some states, you cannot purchase a Medigap plan if you are under 65.
  • If it sounds too good to be true…it probably is. Read the fine print, ask for help from financial counselors, social workers or patients advocates. Counselors are also available through the State Health Insurance Assistance Programs (SHIPS)
  • Take stock of the potential financial implications—short and long term—for any insurance plan you elect. 
  • Use the plan finder to identify plans available in your area and compare costs.
    • Remember that these insurance companies are trying to get your business whereas is a government-operated website focused on providing you with objective information to compare plans available in your area BEFORE you contact a specific company.

In this age of increasing #financialtoxicity, especially in cancer care, patients must be educated about their coverage and their potential costs. You need to resist the lure of “added benefits” and do the work to decide what is in your best interest. I know this is a lot to ask when you are already juggling side effects, treatment schedules and trying to live your lives. But, we can’t just put our heads in the sand and hope for the best when it comes to our medical bills. 

Learn More

Oncolink Health Insurance Webinar Series

Medicare Interactive 

What are you doing to learn more about your coverage, how to maximize it and how to plan for your out-of-pocket expenses?

Christina is a clinical oncology social worker who joined the OncoLink team in 2014. Christina blogs about resources available to the cancer community, as well as general information about coping with cancer practically, emotionally, and spiritually. Christina is also an instructor at the Penn School of Social Policy and Practice and the Financial Navigation Specialist for the Cancer Support Community Helpline. In her spare time, she likes to knit and volunteer with her therapy dogs, Linus, and Huckleberry. She also loves to travel, cook, and is an avid Philly sports fan.

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