3 Reasons to Not Enroll in Medicare Advantage

Advertisements for Medicare Advantage get crazier and crazier every year. You’ll see a flood of TV advertisements, and you’ll probably hear from a telemarketer (or ten)! Medicare Advantage plans can be a huge asset, but they can also present many problems. Today, we’re going to discuss three reasons not to enroll in Medicare Advantage.

What Is Medicare Advantage?

Before we dive in, it’s important to understand a few basic concepts about what Medicare Advantage is and how it works. Medicare Advantage, also known as Medicare Part C, has been around for more than a decade. It is one of four parts of Medicare, the others begin Parts A, B, and D. 

Parts A and B make up Original Medicare, which is offered by the federal government. Medicare Part D offers prescription drug coverage. The fact that Medicare Advantage is considered a part of Medicare makes it a little confusing. In reality, if you enroll in Medicare Advantage, you’ll no longer get your benefits from the federal government. Instead, you’ll get them from which private insurance carrier you choose to enroll with. This means that the carrier has control over claims processing instead of the Centers for Medicare and Medicaid Services (CMS).

So far, none of this is necessarily a bad thing. Medicare Advantage plans are still regulated by the government, so they can’t deny claims for no reason. Plus, they have very low monthly premiums (many as low as $0 per month), and always have a maximum out-of-pocket, which limits what you’ll spend on approved services during the calendar year.

Now that you have a basic understanding of how Medicare Advantage plans work let’s jump into the three reasons not to enroll in Medicare Advantage.

1. Provider Network Restrictions

Medicare Advantage plans rely on provider networks. You’ll need to seek care from providers and facilities that participate in whatever plan you’re enrolled in. Depending on where you live, you may have many options or very few options. If you have providers that you love, you should find out if they accept your plan before you decide to enroll. 

Some plans do allow you to see providers outside of the network. However, it’s important to note that you will pay more to do so. Other plans, like HMOs (Health Maintenance Organizations), do not offer any coverage outside the plan’s network. In addition, if you go out-of-network, the provider does not have to file your claim, which means that you would be responsible for filing the claim yourself.

2. Missing Your Medigap Open Enrollment Window

Medigap plans are also called Medicare Supplement plans. When someone enrolls in Medicare, they’ll either choose to enroll in Medicare Advantage or a Medigap plan. (You can’t have both.) Medigap plans work differently than Medicare Advantage plans. Instead of replacing your benefits under Parts A and B, Medigap plans act as a secondary insurance plan. They’ll pick up some or all of the out-of-pocket costs that Original Medicare would otherwise leave you to pay.

Every Medicare beneficiary has a 6-month Medigap open enrollment period that begins on their Part B effective date. During those six months, you can enroll in any Medigap plan offered in your state. Your current or past health conditions will not be taken into account, and you won’t pay higher premiums because of your health history. However, once that 6-month window closes, you won’t enjoy the same guaranteed issue rights.

If you choose to enroll in Medicare Advantage instead of Medigap, know that you may never be able to get a Medigap plan again. You will have a 12-month trial period the first time you enroll in Medicare Advantage. If you decide you don’t like your Medicare Advantage plan, you can switch back to a Medigap plan. Outside of that situation, you’ll have to undergo medical underwriting in order to get a Medigap plan. Those with chronic or serious health conditions are unlikely to pass underwriting.

3. Skilled Nursing Care

Medicare Advantage plans often require prior authorization for intensive (expensive) treatments. One of the most common prior authorization requirements is for skilled nursing care.

Medicare Advantage plans require facilities to submit prior authorization for skilled nursing care to provide that you need extended care. CMS enforces the same requirements on Original Medicare but is less strict than Medicare Advantage plans seem to be. Sometimes, the private insurance companies are more stringent on their rules, which creates an issue when someone really needs skilled care.

Get Medicare Help from Local Medicare Specialists

Now that you know more about why not to enroll in Medicare Advantage, we also want you to know that these plans can be a great fit for many people. The percentage of Medicare beneficiaries enrolled in Medicare Advantage instead of Original Medicare continues to increase every year.

All we ask is that you work with a local insurance agent in Arizona before deciding if Medicare Advantage is right for you. Our advisors will take the time to learn more about you, your healthcare needs, and your budget, before offering you tailored advice. Call our office today to speak to a local Medicare advisor near you.