Question: My sister is thinking of enrolling in a Medicare Advantage plan. In our practice, we have issues with pre-authorizations and denials. I’ve warned her about network issues. Is there anything else I should tell her?
Answer: I’m so glad you asked. I’ve had this conversation with my own family and friends.
If you enroll in a Medicare Advantage plan and then want to return to original Medicare, you may not be able to get a supplemental Medigap plan. If you enroll in original Medicare when you are first eligible, you are guaranteed to be able to obtain this secondary coverage. But, unless you live in Connecticut, Maine, Massachusetts or New York, your application for a Medigap plan can be rejected for pre-existing conditions.
This is a big deal. With Part B alone, a patient can have large out of pocket costs. There isn’t an upper limit on how high those costs can be. So, enrolling in a Medicare Advantage plan can keep you locked into Medicare Advantage because even if you want to switch to original Medicare, you may not be able to get a Medigap plan.
Low premiums, additional benefits, network issues
You may be locked in and not able to switch back to original Medicare, is that all that bad? There are low premiums and additional benefits that beneficiaries in original Medicare may not be eligible for.
One word: Network. Many Medicare Advantage plans are HMOs. That is, there are in-network and out of network benefits. If you’re diagnosed with a serious condition, will the physician you want to see be in network? What if you need care when you are traveling? There have been news articles about Medicare Advantage plans limiting access to rehab.
Here is an example:
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You can read more about that here:
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