The Medicare system has been around for over 50 years, but that doesn’t mean it’s easy to understand. Oftentimes people try enrolling on their own without any assistance, the process can be hard to understand and the end result is that Medicare Advantage plans get a bad name.

Many people enroll and are happy with the benefits specific to their Medicare Advantage plan. Unfortunately, a large number of people do not have a good experience. Why is there such a disparity?

Usually the culprit is that important details were missed during the selection of the plan and then the beneficiary winds up stuck with a plan they are not happy with. It’s not that the plan is bad, it’s just that it is not right for the individual.

There are many reasons why people feel like a Medicare Advantage plan is bad. The most common complaint is that the plan has them paying more out of pocket than they planned on.

Costs can vary widely depending on the plan you enroll in. When choosing between the available options, pay close attention to what the premium is compared to the out-of-pocket expenses when it comes to copays.

A low monthly premium may seem attractive, but the downside is that you’ll have a copay for each office visit, or service. For example, when a visit to your primary care physician ends up with a referral to a specialist, you’ll be paying two copays. Add in a copay for a CT scan or follow-up bloodwork, and you’re going to be wondering why you’re paying so many bills.

It’s not the plan’s fault, it’s just not a good fit for your situation.

Before you enroll, make sure that you closely review the Summary of Benefits for the plan. You’ll have a clear-eyed view of what to expect when you do, and you can adjust your budget accordingly.

Your Plan is Not Free

Basically, when you enroll in a Medicare Advantage plan, Medicare pays the insurance company to take on the risk of your plan. Then, the insurer can charge you whatever it wants to for the plan.

Often, a Medicare Advantage plan may have a low premium. This is where confusion can occur. Even if your premium is $0 a month, you’ll still have to pay for Medicare Part B the entire time you’re enrolled.

Your Network Will Be Smaller

A Medicare Advantage plan is likely to have a local or regional network. This means the network may only have a limited number of providers. Original Medicare, on the other hand, when combined with a Medigap plan, will give you access to hundreds of thousands of providers nationwide.

Most don’t realize this and they don’t check with their local providers to confirm they are in the network. When this happens, they will be turned away because their coverage is not accepted.

Plans Change

The benefits in any Medicare Advantage plan can change every year. This includes changes to the plan’s provider and pharmacy networks, premiums, copays, coinsurance, and even deductibles. Medications listed in the plan’s formulary are also subject to change.

Each year you must pay special attention to the changes and be extremely detailed in your examination of what your plan offers. If you need to make a change to your coverage, use the fall Medicare Annual Election Period to find a plan with the benefits you need.

The Annual Notice of Change that comes to you each September will spell out any changes so you can then plan whether or not you want to make a switch. If you don’t pay attention to the fine print, you are likely to wind up disappointed in your benefits.

Pre-Authorizations

When a Medicare Advantage plan is reviewing claims, they are always looking to make sure something is reasonable and necessary – and they are looking to make money. Usually, this involves a requirement for your provider to attain a pre-authorization before any prescribed service or medication is approved.

It is important to remember that authorizations sometimes get denied – especially when it comes to medications. This is yet another reason to pay attention to what is spelled out in the summary of benefits, and any changes to coverage the insurer makes.

Out-of-Pocket Limits

All Medicare Advantage plans all have a cap on out-of-pocket spending. This protects you from spending past a certain limit each year for Part A and B services. As of 2022, out-of-pocket expenses can be as high as $7,550 per calendar year. If you’re on a fixed income, coming up with that much extra money can become a heavy burden.

If you’re concerned about such a high amount of expense, you may want to think about a Medigap plan instead. With Medigap, your expenses will be more predictable.

Talk to an Expert

Don’t be disappointed with your Medicare Advantage plan. Avoid the pitfalls by talking with an expert. Take our quick quiz to see what benefits you may be missing out on, and then talk to one of our pros about your individual needs. Together we can help you find the best possible plan for you.

If you’ve got questions, we’ve got answers about Medicare Advantage. Click here to take our quiz and we’ll be in touch.