Making a decision about Medicare? Here’s what you need to know.

Medicare Advantage is not the same as traditional Medicare. There are key differences that can have a real impact on how, when, and where you get the medical care you might need. Each Medicare Advantage plan is also different. Comparing each plan’s covered benefits, limits, provider networks, restrictions, and cost-sharing requirements can be challenging, and it can be hard to know if a specific plan will meet your needs should you get injured or sick or become disabled.

Join us for an educational session with Tim Rye of Peterson Health and Margie Jetton of Advanced Insurance Group for a comprehensive overview of your options and a chance to have all your questions answered before open enrollment begins.

Comparing Traditional Medicare to Medicare Advantage (MA)

ACCESS TO DOCTORS

Traditional Medicare: Almost all doctors participate in traditional Medicare. You can see any doctor or provider, anywhere in the country.

Medicare Advantage: Most MA plans limit the doctors or providers you can see.If your doctor recommends a specialist, he or she may not participate in your plan.

REFERRALS TO SPECIALISTS

Traditional Medicare: No referrals required to see a specialist.

Medicare Advantage: Referrals or prior plan approval are almost always required before you can see a specialist.

ACCESS TO CARE WHEN TRAVELING

Traditional Medicare: Services are covered no matter where you are in the U.S.

Medicare Advantage: Coverage is usually limited to doctors and services in the plans’ network and geographic area.

HOSPITAL STAY LIMITS

Traditional Medicare: None. Your doctor decides how long you need to stay in the hospital based on your condition and needs.

Medicare Advantage: Your plan may limit how long you can stay and make decisions about your treatment that differ from your doctor.

COVERAGE FOR LAB, X-RAY, AND DIAGNOSTIC SERVICES

Traditional Medicare: Your doctor decides with you if you need a diagnostic procedure.

Medicare Advantage: Most MA plans require them to approve a request for a diagnostic procedure.Requests for approval can take up to 3 days and may be denied based on their determination of necessity, not your doctor’s.

COVERAGE FOR HOME HEALTH AND MEDICAL EQUIPMENT

Traditional Medicare: Your doctor decides with you if you need home health or medical equipment.

Medicare Advantage: Most MA plans require them to pre-approve any request for home health or medical equipment. Requests for approval can take up to 3 days and may be denied based on their determination of necessity, not your doctor’s.

What Seniors Need to Know During Open Enrollment

Medicare Open Enrollment: October 15, 2024–December 7, 2024

Every year during open enrollment, current Medicare enrollees have the option to:

1. Switch from one Medicare Advantage plan to another or
2. Switch to traditional Medicare coverage or
3. Switch from traditional Medicare coverage to Medicare Advantage coverage

FAQs About Medicare Advantage

Isn’t Medicare Advantage(MA)a cheaper option for seniors?
Not necessarily. It’s true that MA plans have an annual cap on your out-of-pocket costs ($8,850 for 2024). But, you may incur unexpected costs if you see a doctor or specialist who isn’t in your plan’s network of providers. You may also incur large unexpected costs if you need care while traveling or if you need to stay in the hospital longer than your plan allows. You might also incur costs by having to travel outside of your community to see a doctor who is in your plan’s network.

Can’t I just switch back to traditional Medicare if my plan isn’t working for me?
You can only switch back to traditional Medicare during the federal government’s “Medicare Open Enrollment” period (October 15–December 7). The potential risk for enrolling in a Medicare Advantage plan, even temporarily, is that it can make getting supplemental Medigap coverage more difficult and expensive. Most seniors who choose traditional Medicare will also want Medigap coverage to help pay for out-of-pocket costs.

Medigap coverage is most affordable whenyou first become eligible for Medicare. That’s because the cost isn’t dependenton any medical conditions you have, prescription drugs you use, ornumber ofdoctors you see. If you wait to purchase Medigap coverage until you switch from a MedicareAdvantage plan to traditional Medicare, the cost of your Medigap coverage willbe underwritten, meaning your medical history and pre-existing conditions factor into the cost. If you’ve used your Medicare Advantage plan for medical care, your Medigap policy will be more expensive than if you opted for traditional Medicareplus Medigap coverage when you first became eligible for Medicare.

Aren’t Medicare Advantage plans a better deal because they offer more services than traditional Medicare?
Many MA plans do offer “perks,” like gym or Silver Sneakers memberships, and some offer benefits not covered by traditional Medicare like hearing, vision, and dental. Medicare enrollees need to carefully weigh the value of these perks against the possible hefty out-of-pocket costs for hospital stays, surgeries, medical equipment, x-rays, lab services, ambulance transport, and other services often needed by individuals who are sick or who have an injury or disability.

Medicare Advantage plans do not cover any care you might need when you travel. If you’re visiting family or friends in other cities or states and need medical care, your plan is unlikely to pay for it. Medicare Advantage plans also do not cover “swing bed services.” You might not think about swing bed services when you’re healthy. But, only traditional Medicare will pay for you to stay in the hospital for extra recovery time and to get rehabilitation services like physical therapy after a procedure like a knee replacement or after an illness. Swing bed services can take place in your local hospital, and you get the care and looking after you need to have a healthy long-term recovery. With Medicare Advantage coverage, you have to go home once the plan decides it is not medically necessary for you to be in the hospital.

There are so many choices. What does the hospital recommend?
Medicare coverage should provide peace of mind and help seniors access the care they need close to home with doctors and providers they know and trust. The safest choice is to select traditional Medicare and purchase a Medigap supplemental policy as soon as you become eligible for Medicare. If you want to choose a Medicare Advantage plan, carefully compare the choices and ensure your current doctors and providers are in the network and consider what your future health care needs might be and if all prescribed treatment and care would be covered adequately.