Originally Printed in the Pope County Tribune, October 14, 2019; Content updated October 29, 2021

Residents eligible for Medicare have already been inundated with marketing and advertising about Medicare Advantage plans. That’s because the open enrollment period for Medicare for seniors begins Tuesday, Oct. 15, and runs through December 7.

There may be confusion about whether or not to sign up for the traditional Medicare plan with a Medigap policy or choose a Medicare Advantage plan. And there are some pitfalls that many Medicare Advantage enrollees don’t find out about (the limitations of their Medicare Advantage plans) until they get sick.

The marketing effort pushing the Medicare Advantage plans show the plans are adding some benefits not typically covered by Medicare. But, those added benefits should be carefully considered, since some Medicare Advantage plans, which are privately run versions of the government’s Medicare, can restrict access to a network of doctors or hospitals, cause delays in procedures and limit care, it was recently reported in the Star Tribune. Traditional Medicare doesn’t do that.

Edit 10/29/21: As you are probably aware from a Medicare notice sent in October 2021 to most Medicare age residents in Pope County, Humana is no longer offering Advantage plans in Pope and 11 other counties in MN for 2022. Patients with those plans need to switch or they’ll have costly charges for being out-of-network!)

Some, who were dissatisfied with the Medicare Advantage plan they signed up for last year, can use this open enrollment to switch plans or opt for the traditional Medicare plans. And, those who sign up for a Medicare Advantage plan during that open enrollment period, but later regret their choice, can make one change in the first three months of the following year. The second window applies only to those who already signed up for a Medicare Advantage plan, it was stated on the medicare.gov website.

Pitfalls of Medicare Advantage Plans

Medicare Advantage also referred to as Medicare Part C, plans may sound enticing. As one plan, it combines Medicare Parts A and B benefits and may cover prescription (D) and other benefits. Many offer $0 premiums, but the devil is in the details. You will find that most have unexpected out-of-pocket expenses when you get sick and only want you as a customer when you’re healthy.

Also known as Part C, these plans, which private insurers provide as an alternative to traditional Medicare, must provide the coverage required by Medicare at the same overall cost level. However, what they pay can differ depending upon your overall health.

Coverage Choices When You Qualify for Medicare

When choosing medical coverage as a senior citizen 65 years old and over, you can make one of three choices:

• Traditional Medicare, which has co-pays and deductibles.
• Traditional Medicare with Medigap (a private supplemental policy) covers Medicare’s co-pays and deductibles.
• Medicare Advantage, private insurance that varies greatly depending on the policy you choose.

Key Takeaways…

• A Medicare Advantage (MA) plan, known as Medicare Part C, provides all of Part A and B benefits and sometimes Part D (prescription) and other benefits.
• All Medicare Advantage providers must accept Medicare-eligible enrollees.
• Sick participants may find that medical care costs skyrocket under a Medicare Advantage plan due to co-pays and out-of-pocket expenses.
• Medicare Advantage customers can switch back to Traditional Medicare once per year during the annual enrollment period.
• If you switch from Medicare Advantage to traditional Medicare with a Medigap, most Medigap policies charge you a higher rate than if you had initially enrolled in a Medigap policy when you first qualified for Medicare.
• Prospective Medicare customers benefit from researching plans, reviewing co-pays, out-of-pocket costs, and eligible providers.

Most Comprehensive Coverage

The most comprehensive coverage, which will likely result in the fewest unexpected out-of-pocket expenses, is a traditional Medicare plan paired with a Medigap policy. Medigap policies vary, and the most comprehensive coverage is offered through Medigap Type F. With Medigap Type F, all co-pays and deductibles are covered, and you even get some coverage when you travel outside the country. With this combination, you can go to any doctor who accepts Medicare. Be aware that with traditional Medicare and Medigap, you will also need part D prescription drug coverage.

The Big What-if of Medicare Advantage

(Edit 10/29/21) As Carla Fried writes for an article on MSN, Medicare Advantage is cheaper for a reason – beware.

“If you are lucky enough to be healthy when you’re ready to enroll in Medicare — for most folks it’s at age 65 — the vital “what-if” you should consider: what plan you want if you are diagnosed with cancer or another serious illness that requires lengthy and costly medical care.

If you are willing to ponder that possibility, you will find that the Medicare option that looks so enticing when you’re healthy (likely with no extra premium and expanded coverage) becomes costly when you actually need to use it.”

You can see how a Medicare Advantage Plan cherry-picks its patients by carefully reviewing the co-pays in the summary of benefits for every plan you are considering. To give you an example of the types of co-pays you may find, here are some details of in-network services from a popular Humana Medicare Advantage Plan in Florida (rates as of 2019):

• Ambulance – $300
• Hospital stay – $175 per day for first 10 days
• Diabetes supplies – up to 20% co-pay
• Diagnostic radiology – up to $125 co-pay
• Lab Services – up to $100 co-pay
• Outpatient x-rays – up to $100 co-pay
• Therapeutic radiology – $35 or up to 20% co-pay depending on the service
• Renal dialysis – 20% of the cost

As this non-exhaustive list of co-pays demonstrates, out-of-pocket costs will quickly build up over the year if you get sick. The Medicare Advantage plan may offer a $0 premium, but the out-of-pocket surprises may not be worth those initial savings if you get sick. “The best candidate for Medicare Advantage is someone who’s healthy,” says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. “We see trouble when someone gets sick.”

Switching Back to Traditional Medicare

While you can save money with Medicare Advantage when you are healthy, if you get sick in the middle of the year, you are stuck with whatever costs you incur until you can switch plans during the next open season for Medicare. At that time you can switch to traditional Medicare with a Medigap, but Medigap can then charge you a higher rate than if you had initially enrolled in a Medigap policy when you first qualified for Medicare.

Most Medigap policies are issue-age-rated policies or attained-age-rated policies, which means that when you sign up later in life you will pay more per month than if you had started with the Medigap policy at age 65. You may be able to find a policy that has no age rating, but those are rare.

A Doctor’s Experience With Medicare Advantage Plans

In 2012, Dr. Brent Schillinger, former president of the Palm Beach County Medical Society Services Foundation pointed out a host of potential problems he encountered with Medicare Advantage plans as a physician. Here’s how he describes them:

• Care can actually end up costing more, to the patient and the federal budget, than it would under original Medicare, particularly if one suffers from a very serious medical problem.
• Some private plans are not financially stable and may suddenly cease coverage. This happened in Florida in 2014 when a popular MA plan called Physicians United Plan was declared insolvent, and people were called by doctors who canceled their appointments.
• One may have difficulty getting emergency or urgent care due to rationing.
• The plans only cover certain doctors, often drop providers without cause, breaking the continuity of care.
• Members have to follow plan rules to get covered care.
• There are always restrictions when choosing doctors, hospitals, and other providers, which is another form of rationing that keeps profits up for the insurance company but may limit patient choice.
• It can be difficult to get care away from home.
• The extra benefits offered can turn out to be less than promised.
• [Plans that include coverage for Part D prescription drug costs] may ration certain high-cost medications.

The Bottom Line

Shop very carefully if you are thinking of using a Medicare Advantage plan. Be sure to read the fine print, and get a comprehensive list of all co-pays and deductibles before choosing one. Also, be sure to find out if all your doctors accept the plan and if all the medications you take (if it’s a plan that also wraps in Part D prescription drug coverage) will be covered. If the plan doesn’t cover your current physicians, be sure that its doctors are acceptable to you and are taking new patients covered by the plan.