Medicare Expert: 3 Reasons to Avoid Enrolling in Medicare Advantage

There are legitimate reasons to consider the plans, but certain nuances are also a huge part of the conversation.


After personally talking to thousands of Medicare beneficiaries, I've seen just about everything you can imagine. And some of the craziest things I have seen have involved Medicare Advantage plans. There is a feeding frenzy around Medicare Advantage right now, and it's clouded with both private equity-backed and publicly traded companies flooding the market with inexperienced agents and misleading advertisements. It gets worse every year in the fall due to the surge in advertising around this topic. Hopefully in this article, I can help clear up some of the confusion. Keep in mind I'm not saying Medicare Advantage should never be considered as an option — but in my experience, it is all too often pushed as a one-size-fits-all solution by people who have not been properly trained.

First of all, it is very important to establish some basics around what Medicare Advantage is. Over a decade ago, Medicare Part C was approved as an option for beneficiaries. The fact that it is considered a part of Medicare makes it extra confusing. Medicare has four parts. Parts A and B make up traditional Medicare. This is the public option of Medicare where the Centers for Medicare and Medicaid Services (CMS) administers claim approval for beneficiaries. Part D is the stand-alone drug coverage. For most of my clients, I recommend having Parts A and B with a Part D plan, and a Medigap plan to cover some holes in Parts A and B. The alternative option is to choose Part C, which often bundles the other three parts together and is administered by a private company. When this happens, the private company gets to make decisions about your claims approvals instead of CMS.

Now, this alone is not necessarily a dealbreaker, but it's something that many salespeople do not talk about when selling the plans. These Part C plans normally have a maximum out of pocket that is between $3,500 $7,500, and a $0 premium. This can make them an appealing way to protect yourself against unforeseen out-of-pocket without having to pay a premium. However, there are a few more nuances to the plans that should be considered.

Provider Considerations

Medicare Advantage plans have a network of providers. These provider networks have vastly improved recently, but they can still cause issues. HMOs are health maintenance organizations, and PPOs are preferred provider organizations. These are the two most common types of Part C plan networks. Many agents sell PPOs as an indicator that you can use any provider, whether in or out of the PPO. However, if you go out of the PPO, watch for higher costs and an elevated maximum out of pocket. Also, the provider may refuse to file the plan, which means you'll have to file your own claims. We have seen this happen with one of the nation's largest Medicare Advantage carriers for the last three years. Again, this is not a reason to completely avoid the plans, but it is something to be aware of. Many call centers will tell people that these providers and hospitals are "in network" because it is a PPO and they think it'll pay them. This is very inaccurate and can cause a ton of issues for beneficiaries down the road.

Medigap Open Enrollment

Medigap is often referred to as the alternative to Medicare Advantage. When someone is more than six months away from their 65th birthday or their Part B effective date, they have to answer health questions to get a Medigap plan. When someone first turns 65 or enrolls in Part B, they can get a Medigap plan without answering health questions. Many people decide to try the Medicare Advantage option first because they want to test it while they're healthy. They like it for two or three years while they're not having to use it much, but then they get sick and experience higher out-of-pocket costs and perhaps some issues with claims. Then they go to an agent and ask to be moved to a Medigap plan. Now that health issues have arisen, this can be very difficult. It might be impossible to get through underwriting, or sometimes the best case is that it is costly.

Skilled Nursing Care

Historically, there are very few issues with skilled nursing care when billing original Medicare. Most of the hysteria about Medicare Advantage online comes from people involved with the billing process of rehabilitation services, assisted living, skilled nursing, etc. Medicare Advantage requires them to get prior authorization and continue to prove that someone needs extended care. Interestingly, they use the same requirements as Medicare to make sure the condition requires continued custodial care, but CMS as an organization is paid for by taxpayers and seems to be less strict on enforcing these standards. My experience suggests that private Medicare Advantage companies seem to sometimes be too harsh in their claims denials on these scenarios. This creates a real issue when someone is in a very vulnerable state. Often the person making decisions for the insured isn't the one paying for things — they're just dealing with getting the care necessary for their sibling or parent. This can make the rhetoric around these plans highly divisive.

Now that we have gone over these three reasons, please understand there's legitimate reason to still consider the plans, but these nuances are also a huge part of the conversation. Consider using a local experienced agent to help with decisions.

The information provided here is not investment, tax or financial advice. You should consult with a licensed professional for advice concerning your specific situation.

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