As you approach age 65, you’ll have some decisions to make about medical coverage. On one hand, you can enroll in Medicare. But you may be tempted to choose another option instead: a Medicare Advantage (MA) plan instead. If you’ve seen the advertisements for MA plans, you might think they’re more cost-effective and comprehensive than Medicare. But according to Keith Armbrecht, Founder of Medicare education company, Medicare on Video, that’s not necessarily true.
“I would never choose a Medicare advantage plan,” he says in a YouTube video entitled “Why Medicare Advantage Is The Worst Choice For Seniors.”
Here’s why he’s not a fan of these plans.
What is a Medicare Advantage plan?
Medicare Advantage plans are alternative insurance plans to Medicare, and they’re offered by Medicare-approved private companies. These plans are sometimes called “Part C” or “MA,” and they include Medicare Part A (hospital insurance) and Part B (medical insurance).
Those interested in MA have more than 40 different plans to choose from. The main
reasons to explore them include:
- The potential for lower premiums compared to Medicare. In 2022, the average premium was $58, according to 2022 data from the U.S. Senate Committee on Finance.
- Out-of-pocket costs may be capped. In 2023, the maximum was $8,300 for approved services.
- Most plans include dental, vision, hearing and fitness benefits.
That being said, there are a few downsides to Medicare Advantage plans. Here are some important things to consider before locking into an MA plan.
Limited choice
If you opt for an MA plan, your choice of doctors can be limited and you’re likely to face obstacles in getting approved for procedures or seeing specialists. “The primary reason I would absolutely choose original Medicare and would never choose Medicare Advantage is because I want control over what I do,” says Armbrecht. With an MA plan, he warns, you can face wait times of “weeks, even months,” to get referrals or have procedures authorized.
You’re typically limited to doctors in the plan network and service area, as well,
according to the government’s Medicare website.
Deceptive marketing
The Medicare Advantage plan industry has a history of deceptive practices. In 2022, the Majority Staff of the U.S. Senate Committee on Finance found that Medicare beneficiaries were being inundated with aggressive marketing tactics, false and misleading information and overall predatory marketing from MA providers. According to the report, deceptive Medicare Advantage marketing practices are, “widespread, not isolated events.”
According to a 2022 review from the New York Times, four out of five of the largest MA providers (UnitedHealth, Humana, Elevance and Kaiser) have faced federal lawsuits for fraud and at least eight providers overbilled, according to the U.S. Department of Health and Human Services Office of the Inspector General.
Denied claims
Multiple studies have shown MA plans have a pattern of denying claims that should be covered.
A 2022 review from the Inspector General’s office found that MAs denied 13% of prior authorization requests that met Medicare coverage rules. Essentially, these claims would have been approved under original Medicare. The most commonly denied requests were imaging services, stays in post-acute facilities and injections.
Go to the source
“Medicare is probably the only government program that does exactly what it’s supposed to do and does it very well,” says Armbrecht. In other words, original Medicare is likely your best choice. If you’re nearing 65 and considering your options, you can visit Medicare.Gov for accurate and up-to-date information so you can make the right decision for your health insurance needs.
Medicare’s basic, original Part A (hospital insurance) and Part B (medical insurance) cover obvious things you expect from health insurance: hospital stays, appointments with your doctor when you’re sick, ambulance services, flu shots. But the government’s healthcare program for Americans 65 or older also pays for many things that might surprise you.
If you’re on Medicare or are approaching that time of your life, you’ll want to be aware of these 10 Medicare benefits that enrollees often don’t know about and that can keep you from dipping into your savings.
1. Annual ‘Wellness Visits’
Once you’ve had Medicare Part B coverage for a year, you’ll get what’s called an annual wellness visit with your doctor, who will take routine measurements, such as your height, weight, and blood pressure, and review your medical history. You’ll fill out a “Health Risk Assessment” questionnaire to identify risk factors — so you and your doctor can work on keeping you healthy. Medicare says the appointments also can include “detection of any cognitive impairment.” That means your physician will be on alert for signs of Alzheimer’s or similar ailments.
2. Obesity Counseling
Obesity causes many illnesses and can make frail older bodies much weaker. Diabetes and heart disease rates skyrocket for those who are overweight or obese. Joint and bone diseases are easier to manage at healthy weight levels. If you have a Body Mass Index (BMI) reading of 30 or more, Medicare will cover face-to-face counseling sessions in a primary care setting (like a doctor’s office) to help you bring your weight down to a healthier level.
3. Help to Quit Smoking
If you’re a smoker, Medicare can help you kick the habit. Letting go can be tough, especially if you’ve been a lifetime smoker. To help you break your nicotine addiction, Medicare will pay for eight in-person counseling sessions per year. But note that Medicare’s drug coverage will not pay for stop-smoking products sold over the counter at drugstores, like nicotine patches, lozenges, and gum.
4. Some Hearing Exams
Basic Medicare usually won’t pay for hearing aids or routine hearing tests. But it may cover a hearing exam if your doctor says it’s medically necessary. Hearing is related to balance. When a senior is having balance issues, a physician may want to check the ears to see if there’s an inner ear problem requiring medical treatment.
5. Hospice Care
Hospice care comprises a host of treatments at the end of a person’s life. Medicare will pay for a long list of hospice services, including nursing care, and grief and loss counseling for the patient and family. Hospice coverage applies when a Medicare recipient has been given six months or less to live and has agreed to forgo further attempts at a cure. Medicare-certified hospice care usually takes place where you already live — whether that be at home or in a nursing home. You can also receive hospice care in an inpatient facility. However, it’s important to note Medicare doesn’t cover your room and board, though it may pay for a short-term stay at a hospice facility if your hospice team determines you need that. If you’re dealing with any other health issues not related to your terminal illness, that should also still be covered by Medicare. But the government’s Medicare site points out that’s fairly unusual. Once you select hospice care, the hospice benefit typically covers everything you need.
6. Counseling for Alcohol Problems
Much like smoking, alcohol abuse can have seriously negative effects on the wellness of an older person. Medicare provides alcohol misuse screening and treatment free of charge. It covers one screening per year and up to four brief counseling sessions if the reviewing physician believes a patient needs help.
7. Disease Screenings
Medicare covers screenings for numerous diseases as part of its preventive services. Medicare will pay for testing to detect HIV and other STDs, diabetes, glaucoma, breast and cervical cancer, colon and prostate cancer, and heart disease. Patients with histories of smoking can get an annual lung cancer screening, and Medicare also covers annual screenings for depression and other behavioral health issues that are a concern for seniors.
8. Special Footwear for Diabetes
One of the least-known Medicare benefits is its allowance for specialized shoes for people with diabetes. The disease can cause poor or abnormal circulation in the feet, and a lack of proper treatment can result in the need for amputation. Another risk is diabetic neuropathy, which can damage nerve endings in the feet. Diabetic footwear helps regulate circulation and reduce the danger of neuropathy. Medicare will pay for one pair of custom-molded shoes and inserts and a pair of extra-depth shoes if they’re prescribed and provided by a podiatrist or other qualified health professional. Your insurance will also cover another two pairs of inserts for your custom-molded shoes and three pairs of inserts for extra-depth shoes each calendar year.
9. Wheelchairs and Scooters
Wheelchairs and mobility scooters are important tools to help those with debilitating conditions lead normal lives. Medicare will pick up the cost under certain circumstances. The wheelchair or scooter must be considered medically necessary. Your doctor would need to certify that you are unable to walk without difficulty. The physician would be required to write a prescription for the vehicle or wheelchair after giving you an exam.
10. A Walk-In Bathtub (Maybe)
A walk-in tub can help those with joint problems or other issues that make climbing into a traditional bathtub difficult or impossible. Medicare may help with the cost of a walk-in tub, even though the tubs are not on the list of “durable medical equipment” that Medicare will cover, including wheelchairs, oxygen equipment, and hospital beds. In order for you to obtain coverage, your doctor would have to attest that a walk-in tub is an absolute medical necessity. Medicare wouldn’t provide assistance upfront — after you buy the tub, you’d submit the bill for possible reimbursement. But there’s no guarantee that you’ll get your money back.
Enrolling in Medicare? Here Are Three Key Things You Need to Know — Not Understanding One Can Lead to a Lifelong Penalty
Medicare may seem like a maze when you first try to navigate it. After all, there are different “parts” to the federal health insurance program, which provides coverage for about 56.5 million individuals in the 65-and-older crowd. And, whether you’re reaching the eligibility age of 65 or you are older and switching from workplace insurance to Medicare, there are some important factors to consider that affect your wallet.
First, however, it’s worth knowing the basics: Original Medicare consists of Part A (hospital coverage) and Part B (outpatient care). Some beneficiaries choose to get those benefits delivered through an Advantage Plan (Part C), which typically includes prescription drug coverage (Part D). Others stick with original or basic Medicare and, possibly, pair it with a standalone Part D plan and a so-called Medigap policy.
Here are three key things to be aware of as you prepare to enroll.
1. It’s Going to Cost You
Medicare is not free.
“This comes as a surprise to so many beneficiaries who have paid [payroll] taxes throughout their working lifetimes and assumed this would mean Medicare would be ‘paid up’ by the time they turn 65,” said Danielle Roberts, co-founder of the insurance firm Boomer Benefits.
“Those taxes will mean no premiums for Part A, but Parts B and D have premiums that beneficiaries pay monthly throughout their retirement years,” Roberts said.
Premium-free Part A is available as long as you have at least a 10-year work history of paying into the system via payroll taxes. If not, monthly premiums could be as much as $499 in 2022, depending on whether you’ve paid any taxes into the Medicare system at all. Spouses without their own work history may qualify for premium-free Part A as well.
Part A also has a deductible of $1,566, which applies to the first 60 days of inpatient hospital care in a benefit period. For the 61st through 90th days, beneficiaries pay $389 per day, and then $778 per day for 60 “lifetime reserve” days.
Meanwhile, Part B’s standard monthly premium is $170.10 this year. However, some beneficiaries pay more through income-adjusted surcharges.
“Many of my high-income earners are shocked at how much Medicare premiums will cost them in retirement,” said Elizabeth Gavino, founder of Lewin & Gavino and an independent broker and general agent for Medicare plans.
The government uses your tax return from two years earlier to determine whether you’ll pay extra. To request a reduction in that income-related amount due to a life-changing event such as retirement, the Social Security Administration has a form you can fill out. Part B also has a deductible: $233 in 2022. Once that’s met, beneficiaries generally are responsible for 20% of covered services.
Part D premiums, deductibles, and copays depend on the specifics of the coverage. The average premium this year is about $32, according to the Centers for Medicare & Medicaid Services. And, as with Part B, higher earners are charged extra through IRMAAs.
2. Missing Key Deadlines Can Mean Paying Extra
If you’re planning to sign up for Medicare as soon as you’re eligible at age 65, you get a seven-month “initial enrollment period” that starts three months before the month of your 65th birthday and ends three months after it.
Meanwhile, if you delayed signing up at age 65 because you continued to work and your employer coverage was acceptable (according to Medicare standards), you get eight months to enroll once your workplace plan ends.
Regardless of the enrollment rules you’re subject to, missing the deadline to sign up for Part B can result in a life-lasting late-enrollment penalty. For each full year that you should have been enrolled but were not, you’ll pay 10% of the monthly Part B standard premium.
Part D also has a late-enrollment penalty if you miss the deadline. For people signing up during their initial enrollment period at age 65, you get the same seven months for Part D as you do for Part B. However, if you’re beyond that window and your workplace coverage is ending, you get two months to enroll in Part D, whether as a standalone plan or through an Advantage Plan.
The penalty is 1% of the national base premium for each month you didn’t have Part D or creditable coverage and should have.
3. Supplemental Insurance May Make Sense
The various costs associated with basic Medicare may be different if you have supplemental coverage.
One option is to enroll in an Advantage Plan. While you would generally continue to pay your Part B premiums, many plans have a low or zero premium. And in addition to usually including prescription drug coverage, Advantage Plans also may offer extras such as dental, vision, and hearing.
Advantage Plans come with a cap on out-of-pocket spending, unlike basic Medicare. Their cost-sharing structures — i.e., deductibles, copays, or coinsurance — also are different and vary from plan to plan.
However, the annual maximum out-of-pocket can be high: in 2021, it averaged $5,091, according to the Kaiser Family Foundation. You also may be required to use certain doctors, hospitals, and pharmacies.
“These plans have networks of providers, and some plans will require you to choose a primary care physician and get referrals to see certain providers and prior authorizations for many of the more expensive procedures, tests, and surgeries,” Roberts said.
Your other option is Medigap, which picks up some cost-sharing associated with basic Medicare, such as the Part A deductible or Part B copays. These policies are offered by private insurance companies as well but are generally standardized — same-named plans offer identical benefits no matter which insurer sells it. Available Medigap policies are designated A, B, C, D, F, G, K, L, M, and N, and each offers a different level of coverage.
However, they can be pricey, depending on the insurer and where you live. A 65-year-old woman in Dallas might pay under $100 monthly for Plan G, while in New York that same person would pay $278, according to the American Association for Medicare Supplement Insurance. And, generally speaking, those premiums rise over time.
Choosing between an Advantage Plan or Medigap (or neither) can involve things that go beyond cost and depend on the specifics of your situation. This makes it worth consulting with either an experienced Medicare agent or your local State Health Insurance Assistance Program, otherwise known as SHIP, and neither would cost you anything for guidance.
“There are many factors to consider when choosing between these two options,” Gavino said.
