In Medicare Advantage, also known as Medicare Part C, private companies administer your Medicare plan. These private carriers might offer additional coverage and other advantages, but they may also have their own drawbacks.

Medicare Advantage plans are a popular private insurance alternative to Medicare. However, there are some pros and cons to Medicare Advantage.

While some Medicare Advantage plans offer long-term savings, plan flexibility, and better care, others can lead to fewer provider options, additional costs, and lifestyle challenges.

In this article, we’ll explore some advantages and disadvantages of Medicare Advantage plans, as well as how to enroll yourself or a loved one in Medicare.

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What is Medicare Advantage?

Medicare Part C plans, also known as Medicare Advantage, are sold by private insurance companies. They combine original Medicare (Medicare Part A and Medicare Part B) coverage and often offer additional benefits.

Many Medicare Advantage plans offer the following benefits:

hospitalizationsome home healthcare serviceshospice caredoctor’s visitsprescription drug coveragepreventive caredentalvisionhearingSilverSneakers fitness membershipsTypes of Medicare Advantage plans

There are different types of Medicare Advantage plans to choose from, including:

Health Maintenance Organization (HMO). HMO plans utilize in-network doctors and require referrals for specialists.Preferred Provider Organization (PPO). PPO plans charge different rates based on in-network or out-of-network services.Private Fee-for-Service (PFFS). PFFS plans are special payment plans that offer provider flexibility. Special Needs Plans (SNPs). SNPs help with long-term medical costs for chronic conditions.Medical Savings Account (MSA). MSA plans are medical savings accounts paired with high deductible health plans.

Advantages of Medicare Advantage

Compared to original Medicare, there may be advantages if you choose a Medicare Advantage plan.

Convenient coverage options

Original Medicare only offers two types of coverage: hospital insurance and medical insurance. If you want additional coverage, you’ll need to purchase Medicare Part D for prescription drug coverage and Medigap for supplemental coverage.

With a Medicare Advantage plan, all your coverage options are in one convenient plan.

Personalized plan structures

Medicare Advantage offers different plan types for your personal situation. For example, if you have a chronic health condition, an SNP Advantage plan can help with your medical costs.

If you prefer provider freedom, a PPO or PFFS plan may be more of what you’re looking for. If you want extra services like dental, vision, or hearing, many Medicare Advantage plans include them.

Cost-saving opportunities

Many Advantage plans have no premiums and offer low or no deductibles. Another advantage of choosing Medicare Advantage is that most plans set limits on the maximum out-of-pocket costs you’ll pay during a plan year.

Also, research has shown that you may save money on laboratory services and medical equipment by switching to a Medicare Advantage plan. If you choose a Medicare HMO plan, you may see even more savings on healthcare services provided by your HMO network.

Coordinated medical care

Many Medicare Advantage plans include coordinated medical care. This means that your healthcare providers actively communicate to coordinate your care between different types of healthcare services and medical specialties.

This ensures you have a healthcare team and helps avoid unnecessary expense and issues like medication interactions.

In one study, researchers found that coordinated care was associated with higher patient ratings and more positive medical staff experiences.

Disadvantages of Medicare Advantage

While most people are satisfied with their Medicare Advantage coverage, these plans may also have some disadvantages compared to original Medicare.

Limited service providers

If you choose one of the more popular Medicare Advantage plan types, such as an HMO plan, you may be limited in the providers you can see. You will usually face higher fees if you choose to an out-of-network provider with these plans.

Other plan types do give you more provider freedom, though those plans may have higher premiums and fees like copays and deductibles.

Prior authorization requirements

While traditional Medicare almost never requires prior authorization for services, Medicare Advantage plans tend to add this requirement for procedures.

Ostensibly, this is intended to save money and prevent people from obtaining unnecessary services can create barriers and delays in care.

In 2021, over 35 million prior authorization requests were sent to Medicare Advantage plans.

In addition, in 2022, 99% of all Medicare Advantage enrollees were enrolled in plans that required authorization for certain services. Legislation is in progress to streamline this process, but issues remain.

Frequent denials of service

A 2022 report from the US Department of Health and Human Services Office of Inspector General (OIG) found that many Medicare Advantage plans denied necessary medical services to seniors that are covered by Medicare rules.

In addition, many plans were found to deny payment to physicians for covered services.

Complex plan offerings

Using Medicare’s find a plan tool, you’ll see that there are many Medicare Advantage plan options depending on your ZIP code. For some people, all these options can feel overwhelming.

Check out our Tips for Choosing a Medicare Advantage Plan article to help you narrow down which Medicare Advantage plans are best for you.

Additional costs for coverage

Original Medicare charges a premium, deductible, and coinsurance for both parts A and B, plus any Part D or Medigap costs.

Medicare Advantage plans often consolidate these costs, but you may notice additional fees. For example, many Medicare Advantage plans include drug deductibles and specialist visit copays.

State-specific coverage

Original Medicare offers the same coverage across the United States. However, Medicare Advantage plans may only offer specific coverage in specific service areas. This means that if you move to a new service area, your current Medicare Advantage plan may be unavailable.

Tips to find the best Medicare Advantage plan for your needs

Choosing the best Medicare Advantage plan for your needs can be complicated. There are many things to consider before you decide.

When you’re choosing a Medicare Advantage plan, ask yourself:

How much did I spend on healthcare last year or the year before? This may help determine your budget – how much you can afford to spend on premiums and out-of-pocket costs. Some plans do offer $0 premiums and deductibles, but others may charge a few hundred dollars. What prescription drugs do I take or will I need? If you take medication, you’ll need to find an Advantage plan that includes prescription drug coverage or purchase a Part D plan. Be sure to search any plans drug lists (formulary) to confirm your medications are covered.What types of coverage do I need? Many Advantage plans include extra coverage such as dental, vision, and hearing. You can contact carriers to see what their plans have to offer.What medical conditions do I have, and what are my long-term healthcare needs? More than 40 percent of Americans have chronic health conditions. You’ll also want to consider which plan will suit your long-term medical needs the best.Does my healthcare provider accept Medicare or do they participate in an HMO network? If keeping your current healthcare provider is important to you, you will need to know what Medicare plans they accept or participate in.What is the CMS rating for the plans I’m considering? The Centers for Medicare & Medicaid Services (CMS) uses a Five-Star Rating System to measure the quality of care provided by Medicare Advantage and Part D plans. The CMS star rating measures things like management of chronic conditions, availability of care, member experience and complaints, customer service, drug pricing, and more. CMS releases its star ratings every year.

The takeaway

Medicare Advantage offers many benefits to original Medicare, including convenient coverage, multiple plan options, and long-term savings.There are some disadvantages as well, including provider limitations, additional costs, and lack of coverage while traveling.Whether you choose original Medicare or Medicare Advantage, it’s important to review healthcare needs and Medicare options before choosing your coverage.