John,

During this Thanksgiving week, many of us are seeing our families. Because it’s also Open Enrollment season for Medicare, many of us who are seniors ourselves, or will be seeing older relatives, have an important question on our mind: Traditional Medicare or privatized Medicare Advantage?

Social Security Works senior advisor Diane Archer knows more about Medicare than anyone I’ve met―and she put together seven questions everyone should ask before they make that choice. Here they are:

1. Q. What’s the biggest difference between traditional Medicare and a Medicare Advantage plan? To ensure you have good coverage for both current and unforeseeable health needs, you should enroll in traditional Medicare. In traditional Medicare, you and your doctor decide the care you need, with no prior approval. And, you have easy access to care from almost all doctors and hospitals in the United States with no incentive to stint on your care. In a Medicare Advantage plan, a corporate insurance company decides when you get care, often requiring you to get its approval first. Medicare Advantage plans also restrict access to physicians and too often second-guess your treating physicians, denying you needed care inappropriately. The less care the Medicare Advantage plan provides, the more the insurance company profits. You will pay more upfront in traditional Medicare if you don’t have Medicaid and need to buy supplemental coverage, but you are likely to spend a lot less out of pocket when you need costly care. Regardless of whether you stay in traditional Medicare or enroll in Medicare Advantage, you still need to pay your Part B premium.

2. Q. Should I trust an insurance agent’s advice about my Medicare options? No. Unfortunately, insurance agents are paid more to steer you away from traditional Medicare and into a Medicare Advantage plan, even if it does not meet your needs. While some insurance agents might be good, you can’t know whom to trust. Keep in mind that while Medicare Advantage plans tell you that they offer you extra benefits, you still need to pay your Part B premium, and extra benefits are often very limited and come with high out-of-pocket costs; be aware that many Medicare Advantage plans won’t cover as much necessary medical and hospital care as traditional Medicare. For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114.

3. Q. Why can’t I rely on my friends or the government’s star-rating system to pick a good Medicare Advantage plan? Unlike traditional Medicare, which gives you easy access to the physicians and hospitals you use from everywhere in the US and allows for continuity of care, you can’t count on a Medicare Advantage plan to cover your care from the health care providers listed in their network or to cover the medically necessary care that traditional Medicare covers. Even if your friends say they are happy with their Medicare Advantage plan right now, they are gambling with their health care. The government’s five-star rating system does not consider that some Medicare Advantage plans engage in widespread inappropriate delays and denials of care,¹ and other Medicare Advantage plans engage in different bad acts that can endanger your health. So, while you should never sign up for a Medicare Advantage plan with a one, two or three-star rating, Medicare Advantage plans with four and five-star ratings can have very high denial and delay rates.

4. Q. If I’m enrolled in a Medicare Advantage plan, can I count on seeing the physicians listed in the network and lower costs? Unfortunately, provider networks in Medicare Advantage plans can change at any time and your out-of-pocket costs can be as high as $8,300 this year for in-network care alone. You can study the MA plan literature, and you can know your total out-of-pocket costs for in-network care. But, you cannot know whether the MA plan will refuse to cover the care you need or delay needed care for an extended period. This year alone, dozens of health systems have canceled their Medicare Advantage contracts,² further restricting access to care for their patients in MA, because MA plans make it hard for them to give people needed care.

5. Q. Doesn’t the government make sure that Medicare Advantage plans deliver the same benefits as traditional Medicare? No. The government cannot protect you from Medicare Advantage bad actors. The insurers offering Medicare Advantage plans can decide you don’t need care when you clearly do, and there’s no one stopping them; they are largely unaccountable for their bad acts. In the last few years there have been multiple government and independent reports on insurance company bad acts in Medicare Advantage plans.³

6. Q. If I join a Medicare Advantage plan, can I disenroll and switch to traditional Medicare? You can switch to traditional Medicare each annual open enrollment period. However, depending upon your situation, where you live, your income, your age and more, you might not be able to get supplemental coverage to pick up your out-of-pocket costs and protect you from high costs. What’s worse, you could incur thousands of dollars in out-of-pocket costs in Medicare Advantage.

7. Q. If I have traditional Medicare and Medicaid, what should I do? If you have both Medicare and Medicaid, traditional Medicare covers virtually all your out-of-pocket costs. You will get much easier access to physicians and inpatient services in traditional Medicare than in a Medicare Advantage plan if you need costly health care services or have a complex condition.

During this Medicare Open Enrollment period, ask yourself these seven questions.

And, if you have more questions, please know that you can always call our friends at the Medicare Rights Center at 1-800-333-4114 for free, unbiased advice on any of your Medicare questions.

Social Security Works is continuing to fight to protect everybody who depends on Medicare from the harm that corporate insurers cause. Pitch in $7 today!

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Thank you,

The Social Security Works Team

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¹https://justcareusa.org/oig-finds-widespread-inappropriate-care-denials-in-medicare-advantage/
² https://justcareusa.org/oig-finds-widespread-inappropriate-care-denials-in-medicare-advantage/
³ https://justcareusa.org/oig-finds-widespread-inappropriate-care-denials-in-medicare-advantage/