Medicare Advantage – The Pros and Cons

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September 15, 2022

Premium Choice

Medicare Advantage is a newer health plan that is gaining popularity in the United States. It is paid on a global-risk or full-risk model, where you pay a set amount upfront for your health plan. This model gives you incentives to stay healthy. For example, you’ll get money if you keep your doctor’s appointments and stay out of the hospital.

Closed provider networks

Closed provider networks are a significant issue facing Medicare Advantage plans. In a recent study, KFF looked at the networks of Houston-area Medicare Advantage plans. Unfortunately, none included the University of Texas MD Anderson Cancer Center. In addition, no Houston-area QHP directories listed the university as a participating facility. However, the University of Texas MD Anderson Cancer Center is a participating facility in an FEP plan.

The study found that, in 2011, 64 percent of Medicare Advantage plans had narrow networks, while 99.5% had wide networks. However, health-maintenance and preferred provider organizations (PPOs) had narrower networks than others.

Costs

When you sign up for a Medicare Advantage plan, the cost of your coverage can vary widely. This is because many factors can affect the cost of your premium. Some of these factors are the amount of financial support from Original Medicare, the extras you can get with your plan, and administrative costs. As a result, some of the premiums will be very high, but this does not necessarily mean the plan overcharges you. The best way to determine whether the premium you pay is worth it is to investigate the features and benefits of each plan.

A significant factor that may impact the costs of a Medicare Advantage plan is the cost of co-payments for doctor visits. Some plans also require you to pay a deductible before you are covered. However, you can purchase a Medicare Supplement plan if you have a significant out-of-pocket expense. These plans cover the costs that Original Medicare doesn’t cover.

Prescription drug coverage

You may be eligible for Medicare Advantage prescription drug coverage if you have Medicare. To join a plan, you must have Medicare Parts A and B and reside in the plan’s service area. Some plans don’t cover prescription drugs if you have end-stage renal disease or other severe medical conditions.

Many plans for prescription drug coverage are available through Medicare Advantage, which combines Original Medicare and private health insurance with a prescription drug benefit. The plans differ in coverage and premiums, but most will cover prescription drugs. They may include a monthly premium or a fixed co-payment each time you fill a prescription. Others may require a coinsurance percentage.

Use Medicare’s Finds a Medicare Plan tool to find a plan that offers prescription drug coverage. You can filter plans by area, prescription drug coverage, and monthly premiums. You can also input your medications to determine the prescription drug coverage best suits your needs. The initial enrollment period is three months before you turn 65. The coverage period ends three months after you turn 65.

Prior authorization is required for some services.

Prior authorization is a process that physicians and health plans use to ensure that patients get covered for certain services. The process has three steps that a provider should follow to ensure proper coverage. This is especially important for expensive procedures or medications. Some examples of services that require prior authorization include surgeries in an outpatient setting, MRIs, durable medical equipment, and specialty drugs. Physicians can get the information they need from the plan’s website, but it is good to consult a health care provider before requesting a prior authorization form.

Prior authorization for specific services is a standard process for Medicare Advantage plans. It means that Medicare must approve your request for a particular service before you can use it. Unfortunately, it also means you may not receive the total cost of your treatment. If you’re unsure whether a medical service requires prior authorization, contact your plan’s customer service department to clarify.

Limitations

One of the main reasons for enrolling in Medicare Advantage is the reduction in out-of-pocket health care costs. However, while the benefits are clear, there are also some limitations. For example, Medicare Advantage providers may not offer every treatment a patient needs. This can make Medicare Advantage unattractive to seniors.

Medicare Advantage plans often have restrictions on which doctors and hospitals you can see and may have very high co-payments. As a result, they are best suited for healthy individuals but can be expensive for those with chronic illnesses or injuries. Insurers can also deem certain services not “medically necessary” and terminate coverage for them.

Medicare Advantage plans may also require pre-authorization for specific treatments and procedures. Out-of-network providers may also be more expensive. And people who have a long-term condition are less likely to stay in a Medicare Advantage plan. In addition, the GAO has warned that Medicare Advantage plans may be unfit for older adults. As a result, some experts are calling for stricter government oversight.