The Pros and Cons of Switching to a Medicare Advantage Plan
Last Updated : 06/20/20196 min read
Did you know that most Medicare Advantage plans include prescription drug coverage? Many Medicare Advantage plans have extra benefits as well.
If you’re currently enrolled in Original Medicare and exploring other options, here’s an overview of both the potential benefits and drawbacks of Medicare Advantage (Part C).
Medicare Advantage may offer coverage beyond Original Medicare
One of the main reasons that many beneficiaries consider switching is the extra coverage many Medicare Advantage plans offer.
While all Medicare Advantage plans must provide at least the same level of coverage as Part A and Part B, plans may also include benefits not normally covered by Original Medicare, like:
- Prescription drug coverage
- Wellness programs like SilverSneakers
- Routine vision services
- Routine dental services
- Hearing services
- Meal delivery for beneficiaries with chronic illnesses
Medicare Advantage plans are allowed to include benefits beyond those included in Medicare Part A and Part B.
In some cases, some Medicare Advantage plans might even cover non-medical transportation, such as grocery shopping, if you qualify (due to a chronic illness, for example).
This isn’t a complete list of possible extra benefits Medicare Advantage plans can offer. It’s also important to know that not every plan has the same extra benefits, or availability in your area. Some plans might not have any coverage beyond Medicare Part A and Part B benefits.
Since benefits vary by plan, always check with the specific Medicare Advantage plan you’re considering for more details.
Medicare Advantage offers a variety of plan types
One of the biggest advantages of the Medicare Advantage (Medicare Part C) program is there are so many plan types available, you might just find one that fits your needs and preferences.
For example, if you don’t mind having less provider flexibility for the sake of lower costs, you might consider a Medicare Advantage Health Maintenance Organization (HMO) plan.
Conversely, if you want greater provider choice and don’t mind potentially paying more out of pocket, you could go with the Medicare Advantage Preferred Provider Organization (PPO) plan.
There’s even a Medicare Advantage plan for those who want something in between an HMO and a PPO plan: a Medicare Advantage HMO Point-of-Service plan. These plans give you the structure of an HMO, but may allow you to get some services using non-network providers, usually with higher costs.
Medicare Advantage Special Needs Plans may be particularly helpful for beneficiaries in uniquely challenging situations. These plans offer benefits specially designed for those who live in an institution (like a nursing home); have at least one chronic condition; or those who navigate both Medicare and Medicaid coverage.
Medicare Advantage costs may be lower
Another reason you might like Medicare Advantage is that costs may be lower than Original Medicare, depending on the plan.
Under Original Medicare, costs are generally the same for all beneficiaries when it comes to expenses like Part B premiums, deductibles, and cost sharing.
Under Medicare Advantage, each plan negotiates its own rates with providers. Your costs, like premiums, deductibles, copayments, and coinsurance, may vary from plan to plan.
Some Medicare Advantage plans do not have a monthly premium; however, you’ll still need to keep paying the Part B premium, even if you don’t pay a premium for your plan. Some plans help pay for all or part of the cost of the Part B premium.
Another “pro” of Medicare Advantage when it comes to cost is that all Medicare Advantage plans have a yearly out-of-pocket maximum.
Under Original Medicare, typically there’s no annual cap on your medical costs. That could lead to a financially stressful situation if you have an illness that needs ongoing, expensive treatment.
Under Medicare Part C, all plans are required to have an annual maximum (which varies by plan). Once you meet this limit, your plan covers the costs for all Medicare-covered services for the rest of the year.
Again, out-of-pocket costs vary from plan to plan, so take the time to compare different Medicare Advantage plan options to find one that works for your budget.
Pros and cons of Medicare Advantage: the potential “cons”
There are potential downsides to Medicare Advantage as well, such as:
- Premium: you may have to pay a premium for your Medicare Advantage plan, in addition to your Part B premium. However, some Medicare Advantage plans have premiums as low as $0.
- Provider networks: many Medicare Advantage plans may have provider networks that limit the doctors you can use. Under Original Medicare, you can use any provider that accepts Medicare assignment.
- Coverage when traveling: because you’re limited to network providers, many Medicare Advantage plans only cover out-of-network services in emergencies. For those who travel within the country often or live in another state during part of the year, Original Medicare may offer greater flexibility.
- Doesn’t work with Medicare Supplement: a Medicare Supplement plan cannot help with a Medicare Advantage plan’s out-of-pocket costs.s
Medicare Advantage and end-stage renal disease (ESRD)
Unfortunately, if you have Medicare because of end-stage renal disease (ESRD), you’re usually not eligible for most Medicare Advantage plans. There are some exceptions, like if you develop ESRD while you’re already enrolled in a Medicare Advantage plan.
You may be eligible to enroll in a Medicare Advantage Special Needs Plan if there’s one targeting people with ESRD in your area.
Can I switch Medicare Advantage plans at any time?
Like other types of Medicare coverage, there are set times of the year that you can enroll or make changes. If you’re already in a Medicare Advantage plan, you may switch plans or disenroll during the Medicare Advantage Open Enrollment Period.
If you’re ready to start browsing Medicare Advantage plans in your area, you can get started right now. Just enter your zip code on this page to begin comparing plan options.
Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover an out-of-network, your or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.