Here is What You Need to Know:
“Is it worth opting for Medicare Advantage plans?” Answering this question isn’t straightforward, as there are both advantages and disadvantages to these programs that you should be well-informed about.
Medicare Replacement or Medicare Part C
Before delving into the pros and cons, it’s important to provide some context about Medicare Advantage plans, which are also referred to as Medicare Replacement or Medicare Part C. These plans were created to offer an alternative way for individuals with Medicare Part A (covering hospital and home health services) and Part B (encompassing outpatient services like doctor visits and physical therapy) to receive benefits. They are offered by private insurance companies in collaboration with Medicare. Navigating the intricacies of healthcare can be bewildering, and it seems that staying abreast of developments in this realm has become even more challenging this year. Here, we outline a few advantages and disadvantages associated with Medicare Advantage programs.
- Your advantage plan can be a “one-stop” shop for your prescription drug coverage and health needs;
- Many plans include dental and hearing;
- Some plans can cost $0 a month;
- Some plans include gym discounts;
- If you change to an advantage plan, sometimes some services aren’t covered (for example, physical therapy)
- The coverage for some services and procedures may require a doctor’s referral and plan authorizations;
- You typically don’t receive nationwide coverage;
…So, is it worth it?
In my honest opinion… in most cases, no. I’ll tell you why with stories of our patients.
First patient story
We had a patient once that was on a Traditional Medicare plan (not an advantage plan), and we were working with him on and off for months. He decided to switch to a Medicare Advantage plan without telling us, hoping to save money on medications. However, he didn’t realize his physical therapy wasn’t covered on his new Advantage plan. A few weeks later we realized it and we had to call him and bill him for his therapy appointments, which the advantage plan did not pay for.
Remember one of the cons I mentioned earlier? If you change to an advantage plan, sometimes certain services aren’t covered (such as physical therapy). He continued therapy with us, because he knew it helped and he didn’t want to give it up and miss out on achieving his goal of taking a trip to Italy without depending on his walker! Luckily, after spending hours on the phone he was able to switch back to his traditional Medicare plan.
Unfortunately, he went 3 weeks without therapy and did slide backward a little bit, but in the end, he was able to switch back to traditional Medicare and continue moving towards his goals. So, make sure you ask questions about your new coverage before making the switch to an advantage plan.
Second patient story
Jane was one of those clients. She lived in one of the senior living facilities that we work with, and she often would need home health therapy and nursing for various health issues. Her family had decided to switch to an Advantage plan with Humana.
Her daughter was so great in helping her ask all the questions she needed. She would be able to keep her doctor, and they told her “yes, the plan covers home health therapy and nursing”, and the best part was she would save on monthly medication cost. So, they made the switch.
Everything was going well until she was hospitalized due to a UTI, and had a fall and scraped up her arm. She needed home health nursing and therapy to get her back to her spunky, fun self. She was feeling confident that she would be back to her normal self in a month or two, however, the issue surfaced when her insurance said they would only approve three nursing visits and five therapy visits. The nurse had recommended six nursing visits to make sure the large gash on her arm was treated with the proper wound care, and we all know it take more than five visits of therapy to address the strength and balance problems that she had following the hospital stay and her fall. She was very upset. The home health agency and her doctor fought for more approved visits but ultimately failed.
Jane was now faced with the decision to pay out of pocket for her therapy or accept that she wouldn’t get back to her normal self. It was a terrible situation. She felt cheated and misled. She would now have to wait until next year during open enrollment before switching plans.
It can be overwhelming sometimes if you’re thinking of switching your healthcare plan. That’s why I think it’s important for you to have all the information you need to come to an informed decision. You can make up your own mind on what is best for you, But if you’re asking me, I’d say stick with your Original Medicare plan!