Healthcare costs are continually rising, especially at a time when critical illnesses, like COVID, abound. For those who are age 65 and above, it can be hard to afford health insurance and still get the care you need. 

Many seniors turn to Medicare Advantage Plans, because they offer free premiums, deductibles on certain medications, and free prescriptions. While these may seem like great perks to many people, Medicare Advantage plans are actually bad for certain populations, and many doctors do not like Medicare Advantage plans. The reason for this is that these plans limit you.

But why exactly are Medicare Advantage Plans bad, and why don’t doctors like them? According to experts, those with Medicare Advantage plans have a limited number of doctors they can see, so it may be difficult to find the best doctor for your unique situation. 

While Medicare Advantage often offers free monthly premiums, there are sometimes hidden costs that you may not expect. Some plans may not cover the cost of treatments and tests rendered when you are sick. Because of this, you may have to pay out of pocket for expensive tests. In some cases, treatments your plan will cover will depend upon the state of your health.  

Individuals who are sick may find that medical costs increase significantly, because they are forced to pay out of pocket for unexpected medical procedures and medications. Although Medicare Advantage Plans are supposed to be an “alternative” to regular Medicare, these programs are not available through private insurance companies that work with Medicare to make Part A and Part B benefits available. In fact, the MA plan can cover less than what A & B cover.

In some cases, these plans may cover Medicare Part D prescription medications, known as a MAPD plan. Original Medicare typically does not cover benefits, such as dental and vision. It is important to note that you must sign up for Part A and Part B before you can sign up for a Medicare Advantage Plan.  

Additionally, some people are denied coverage under Medicare Advantage Plans. Many participants with Medicare Advantage Plans are denied benefits for treatments it does not deem medically necessary. According to experts, Medicare Advantage Plans bring another set of problems. 

While Medicare Advantage Plans offer a host of benefits that Original Medicare does not, be aware that these come at a cost. Medicare Advantage Plans offer certain benefits that original Medicare does not. For example, Medicare Advantage Plans offer vision and dental care. 

Be aware, however, that these benefits come at a cost. Experts assert that many individuals aged 65 and above must often spend more than what their budget allows for taking advantage of extra benefits. Once you have exhausted coverage for extra benefits, you must pay for extra services out of pocket. This can put an additional strain on your pocketbook, sometimes making it difficult to get the care you need. 

There may be cases where Medicare Advantage Plans are beneficial. Those on a low fixed income who can’t afford “monthly premiums” may find Medicare Advantage Plans beneficial. However, there are other problems associated with Medicare Advantage Plans. 

According to PubMed, Medicare Advantage Plans do not pay hospitals as much as Original Medicare. Although there is much debate about this issue, studies have found that Medicare Advantage Plans pay hospitals 5.6 percent “less” than what FFS or Fee-For-Service Plans pay hospitals. FFS Medicare is different from Original Medicare. 

How much you pay doctors under FFS Medicare depends on the plan you are using. In addition to disparities in payment, Medicare Advantage Plans come with a number of disadvantages. Medicare Advantage Plans are typically expensive, if you are sick or have copays that are not covered by insurance.

Another problem with Medicare Advantage Plans is the fact that you may not have coverage if you visit doctors who are outside of their coverage area. Requirements for referrals can also be problematic. While the benefits offered by Medicare Advantage Plans may seem enticing, many seniors eventually regret enrolling in the program.

Many of the downsides of Medicare Advantage Plans are financial. Those who stay in the hospital for six days may find that they are forced to pay much more than they would if they had Original Medicare. Stays in the hospital can cost anywhere from $200 to $300 per day for a five to seven day stay. Medicare Advantage Programs can put an additional financial burden on those who already have a hard time affording insurance.

Those with serious health conditions should be especially worried with Medicare Advantage Plans. Many seniors end up paying thousands of dollars to see providers that are out of network. Those who are on Original Medicare can usually see providers that accept Medicare.

With Medicare Advantage, however, you are required to get preauthorization if you want to see a specialist. Those who live in rural areas may experience more problems with Medicare Advantage Plans. Those who live in rural areas are often likely to switch back to Original Medicare, if their Medicare Advantage Plans are not working out.

If you wish to see an out-of-network provider on Medicare Advantage, you may be forced to pay higher than normal copays. It may sound convenient to switch back to traditional Medicare, but this is not as easy as you may expect. You may have to wait until your plan’s open enrollment period to switch back to Original Medicare. Until then, you are stuck paying high out-of-pocket costs.

You may be able to switch back outside of these open enrollment periods, if you have a special circumstance, such as admission into institutional care or moving. The rules surrounding Medicare Advantage Plans are different during your first year in the program. Within the first year, you have the option to go back to your Original Medicare Plan.

If you have a Medicare Advantage Plan, you are not able to purchase a Medicare supplement plan, such as Medigap. If you are age 65 or above, it may be tempting to try a Medicare Advantage Plan. However, be aware that extra costs associated with Medicare Advantage Plans add up and can put you in a bad financial position. These plans may be good for those with money saved up for unexpected medical bills.

Another big problem with Medicare Advantage Programs is the fact that they can deny you coverage at any time. Every year, Medicare Advantage denies thousands of requests. This can be especially troubling for those with preexisting conditions that require ongoing care.

Enrollment in Medicare Advantage Plans has increased by 50 percent, and many seniors will pick private insurance over government programs in the coming years, according to The New York Times.  

In 2019, roughly 1.5 million people were denied coverage. Such denials might prevent many seniors from getting the care they need. Although you can appeal these denials, not many seniors do. Medicare.gov provides information on the different types of Medicare and Medicare Advantage options. 

Medicare Advantage Plans can differ. This often depends on the policy you have. Experts say that you see the lowest cost with Original Medicare, as opposed to Medicare Advantage Plans. Medicare plans with a Medigap policy typically are the most comprehensive, and you get the best coverage under Medigap Plan G. 

Medigap Plan G covers all deductibles (except part B $226/year) and copays, and coverage is available for those traveling overseas. When traveling overseas, you can see any doctor that accepts Medicare. However, bear in mind that you may need to use your Part A and Part B benefits for copays and coinsurance payments.

When it comes to Medicare Advantage Plans, you must be more careful. Costs with Medicare Advantage Plans are largely dependent on the state of your health and the amount of care you require. Depending on the care you need, you may have to pay more, and it can be hard to prepare for large medical costs.

Despite the many negatives of Medicare Advantage Plans, insurance companies continue to push them. Premiums are affordable and often free. Medicare pays the insurer whenever someone enrolls. Insurance companies push people to enroll in Medicare Advantage Plans for this reason. 

Original Medicare is better than Medicare Advantage Plans, because you pay the vast majority of your medical cost through your monthly insurance payments. This makes it easier to budget your money and prepare for other medical expenses. With Medicare Advantage Plans, you must pay when services are rendered. 

On average, those enrolled in Medicare Advantage Plans pay $5,070 for services that are in-network annually. However, for PPOs, members can expect to pay $9,000 to see in-network and out-of-network providers. Experts anticipate that these prices will increase. Another problem with Medicare Advantage Plans is that they make you pay “multiple copays” for the same problem.

Medicare Advantage Plans are a pay as you go system. When you go to your primary care physician, you pay a copay. If you are referred to a specialist, you pay yet another copay. If the specialist orders tests, you are paying for those out of pocket as well. 

Don’t expect everything to be covered under your Medicare Advantage Plan. If you find that this plan is not working for you, you must wait for the next open enrollment period to switch back.

6 Sources

MedigapCoverage has strict sourcing guidelines to ensure our content is accurate and current. We rely on peer-reviewed studies, academic research institutions, and medical associations. We strive to use primary sources and refrain from using tertiary references.

https://www.uhc.com/medicare/lp/medicare-advantage-plans

https://www.investopedia.com/articles/personal-finance/010816/pitfalls-medicare-advantage-plans.asp

https://www.healthcare.gov/glossary/medically-necessary/

https://pubmed.ncbi.nlm.nih.gov/27503970/

https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/PFFS

https://www.ncoa.org/article/what-are-the-costs-of-medicare-advantage-part-c