Who Should Consider Medicare Advantage?

Medicare Advantage plans are a great alternative to Original Medicare for many seniors and Americans with disabilities. The national average of customer experience ratings of Medicare Advantage health plans in 2019 was 87 out of a possible 100 points. This rating, which reflects plan performance, indicates that most people who have Medicare Advantage feel that their plan does a good job of meeting their needs. With Medicare Advantage customers rating their health plans so well, it may be tempting to think that Medicare Advantage will be a good fit for anyone who is eligible. However, some people are more likely to benefit from these plans than others. Medicare Advantage may appeal to a wide variety of people, but it isn’t a one-size-fits-all solution.

Below we have outlined several common scenarios in which joining Medicare Advantage is the best option. We’ve also included information on a few scenarios in which one of several coverage alternatives might be a better fit. For seniors who aren’t sure which coverage path to take, this article will provide information that can help you determine if Medicare Advantage is the best option for you and resources for learning more.

Who Should Consider Medicare Advantage for Financial Reasons?

Medicare Advantage plans are designed with multiple features that can save seniors money in the long run. Which features save you the most money depends on your typical use of medical services. Below you can learn about the kinds of seniors that will save the most money by switching to Medicare Advantage.

Seniors Who Need to Reduce Their Yearly Health Costs

Original Medicare does not place yearly out-of-pocket spending limits on a patient’s cost-sharing, but Medicare Advantage does. Patients who use Original Medicare will continue to owe unlimited deductibles, copayments, and coinsurance even if their yearly costs skyrocket due to illness. A 2018 study found that 25% of Medicare patients with “serious illnesses” said that their healthcare is a major financial burden to their families and 53% said that they faced a serious problem with paying medical bills. This study highlights the fact that out-of-pocket costs in Medicare can become unmanageable quickly. For seniors who are struggling to meet their ongoing cost-sharing responsibilities under Original Medicare, switching to Medicare Advantage can provide relief. 

All Medicare Advantage plans, in contrast to Original Medicare, have an out-of-pocket spending limit that includes deductibles, copays, and coinsurance. These limits can be set between $0-$10,000, depending on the plan, but many are around $3,000- $5,000. Knowing that out-of-pocket costs will stop adding up once they reach the maximum can be a relief, particularly for those who are currently forgoing needed treatment, asking family members for help, or putting their medical bills on credit cards.

Tips for Finding a Plan That Will Reduce Your Yearly Costs

Calculate Your Current Spending
If you’ve been using Original Medicare, try to calculate how much you’ve spent on deductibles, copays, coinsurance, and prescriptions over the past year. If you’ve had recent health changes, do your best to calculate what your new treatments would cost out-of-pocket over a year. Once you know (roughly) what your out-of-pocket spending currently is or is likely to be, you’ll be able to tell what kind of out-of-pocket spending limit will benefit you.

Understand Medicare Plan Types
If you’re looking for yearly savings, you’ll want to review the different Medicare plan types so that you know how coverage is likely to work for the plan that you select. Keep in mind that PPOs can have spending limits as high as $10,000, so only choose a PPO if you genuinely think that the high spending limit or other plan features will actually lower your costs.

Remember Premiums
Premiums don’t count towards out-of-pocket spending maximums, but they do still come out of your pocket. Don’t neglect to factor in premiums when trying to decide if a plan will help you or not. Some plans with high premiums have especially low out-of-pocket maximums, so it’s all about choosing the plan that best fits your personal situation. For more information on how premiums work in Medicare Advantage, read “Paying for Medicare Advantage: Costs and Financial Assistance.”

Seniors Who Are Eligible for Both Medicare And Medicaid

Seniors who are considered low-income or who have disabilities are likely to qualify for both Medicare and Medicaid, a status known as dual eligibility. Having both Medicare and Medicaid means that the senior could potentially have a large portion of their medical costs covered. Medicare and Medicaid have their own sets of rules and ways of doing things, and using both programs at once can be overwhelming. Thankfully, in many areas of the country, patients have access to a special kind of Medicare Advantage plan called Dual Eligible Special Needs Plans (D-SNP). These plans can help patients make the most of their access to both programs.

Benefits of Using a D-SNP: 

• Care Coordination: Care coordination is deliberate communication among healthcare providers, usually managed by a single person who is designated the “coordinator”. D-SNP plans can provide a high level of care coordination, helping doctors, patients, and government agencies work together with maximum efficiency. Care coordination reduces healthcare accidents, duplications, and oversights that have adverse financial and physical effects on patients.
• Low Costs: D-SNP plans differ by state, but the focus of these plans is always keeping patient costs as low as possible. Patients using D-SNP plans often have no premiums, copays, or deductibles. They also frequently get coverage on prescription drugs, dental, vision, and other care costs that patients might otherwise pay for out-of-pocket.

Tips for Finding a D-SNP

Check Your Eligibility
D-SNPs are one of the few types of Medicare Advantage plans that aren’t open to everyone who has Medicare. To benefit from the low costs typical of D-SNPs, you need to be enrolled in both Medicare and Medicaid. If you aren’t already receiving Medicaid benefits, then start by looking at the income limits for Medicaid. You may also want to get in touch with your state’s Medicaid office to get help with any enrollment questions that you have.

Understand How Location Impacts Availability
Unfortunately, not every area has a D-SNP available. Private insurance companies have the prerogative whether or not to offer a special needs plan, so availability varies. Moreover, some state Medicaid programs are less cooperative with Medicare than others, making it difficult to run a D-SNP in some locations. Use the Medicare Health Plan Finder to discover if there’s one offered in your county.

Seniors Who Struggle to Afford Their Prescriptions

Original Medicare covers very few prescription drugs. Part B of Original Medicare covers prescriptions that are typically given in the doctor’s office- things like specialized infusions, injections, antigens, and blood-clotting medication. However, it does not usually cover medications that one takes at home on a regular basis. With 45% of seniors in 2019 who were in fair to poor health saying that they found paying for their prescription drugs “difficult,” it’s clear that many seniors need help with purchasing prescriptions. Seniors in need can find relief through Medicare Advantage plans, which, unlike Original Medicare, frequently include robust drug coverage (Part D).

If a Medicare Advantage plan has drug coverage (most but not all do), it will have a formulary (a list of covered and uncovered drugs) that will impact how drugs are categorized and covered. In most cases, a Medicare Advantage drug plan must offer coverage for two different drugs in each category of common conditions. Even if a specific drug you need is not on your plan’s formulary, a similar drug can sometimes be substituted, or you can file for an exception if alternatives do not work for you. Formularies can change in the middle of the year to account for advances in science and changes within drug companies.

Tips for Finding a Plan with Drug Coverage

Search for Your Specific Prescriptions
The Medicare Health Plan Finder enables patients to add specific prescriptions to their health plan search. If you know that you will need to take a specific drug, then you can enter its name into the search tool to see how your copays/coinsurance for that drug will compare in different plans.

Look at Deductibles
Some Medicare Advantage plans that include drug coverage will have a drug deductible that’s separate from the health deductibles. Check to make sure that the deductible is not too high for you. Most plans have $0 drug deductible, but some will have deductibles that may be around $150.

Look at Coverage Tables
Using the plan finder, you can click “plan details” on each plan to discover more about coverage. If you scroll almost to the bottom of the page you will be able to view a table that includes the plan’s rates for brand-name, generic, and “specialty” (uncommon) drugs. Brand name and generic drugs will each have a preferred and non-preferred category in most cases, with preferred categories being less expensive. Comparing the coverage tables of different plans will help you to estimate your drug costs.

Seniors Who Struggle to Afford Hearing, Vision, or Dental Services

Under Original Medicare, there are many vital healthcare items and services that are not covered. Most notably, the majority of hearing, vision, and dental items and services have zero coverage. Under Medicare, seniors cannot get help with purchasing hearing aids, dentures, or glasses. Without proper coverage for these or related items and services, a senior’s mobility, eating habits, and communication skills can all be severely impacted. Problems in all three of these areas are exceedingly common in seniors, as is illustrated by the following facts.

Snapshot of Hearing, Vision, and Dental Health in Seniors: 

• One out of three people between 65-74 have difficulty hearing 
• 91.4% of Americans age 55+ use some form of vision correction
• The average number of teeth that seniors over 65 have is about 19, despite the fact that a full set of adult teeth is 32 teeth

Medicare Advantage plans can fill the care gaps that Medicare leaves in these health categories because many of them carry supplemental coverage. In addition to hearing, vision, and dental, seniors can also sometimes get coverage for things like in-home care and transportation through Medicare Advantage.

Tips for Picking a Plan That Provides Extra Coverage

Prioritize Urgent Needs
While it’s ideal to find a plan that offers you coverage in all of the “extras” that you might need, you may find the plan that does so to be too expensive or to have other undesirable features. If you must make a compromise, try to pick a plan that offers the heaviest coverage in the area you think you’ll need most. For example, if you know that your hearing is getting worse, consider springing for a plan that doesn’t cover eyeglasses but that has a very low copay on hearing aids which typically cost thousands of dollars.

Look Closely at Plan Details 
On the Medicare Health Plan Finder, sometimes a plan will appear to have extra coverage for something, but when you look at the plan details you’ll find that it covers little more than a yearly exam. While this office visit coverage can be helpful, it’s not likely to save you a lot of money. Make sure you know what’s actually covered before you sign up.

Who Should Consider Medicare Advantage for Other Reasons?

Seniors Who Need Long-Term Residential Care

Seniors who need to spend extended time in a residential care setting, such as a nursing home or other skilled nursing facility, face unique needs. Many seniors who use long-term care (“institutional” care according to Medicare language) face health challenges associated with being bedridden, needing continuous physical therapy, high overall healthcare costs, and more. While many needs can be met through Original Medicare, seniors may find that they are happier with the high level of care that a Medicare Advantage plan called an I-SNP (Institutional Special Needs Plan) can provide.

Seniors who have been staying in or are expected to stay in a nursing home or similar facility for 90 or more days can join an I-SNP. Typically, an I-SNP is created when an existing nursing home or other institution decides to also become an insurance provider. When they do this, they usually add extremely useful, high-quality care options to their typical offerings. Extra or more highly qualified staff members and care-coordination services are common additions.

Tips for Finding an I-SNP Plan:

Ask If Your Nursing Home Already Has a Plan
If you’re already residing in a local nursing home and the topic of using an I-SNP hasn’t come up yet, you may want to enquire if the facility has such a plan. If they do, discuss with the staff whether or not you’re a candidate for joining the plan. It may take some time to know whether or not you’ll qualify if your doctors are not sure yet how long your stay will be. You may also want to look into transferring to a facility that has an I-SNP.

Find Out What Happens If you Need to Move
If you’re joining an I-SNP, it’s because you think you’ll need to spend at least 90 days at a particular facility. However, there’s always a chance that your health could improve or deteriorate in an unexpected way, and you’ll need to be moved somewhere else. Some I-SNPs serve just one facility, while others serve many. While you are looking at plans, make a point of knowing the network of facilities that the I-SNP in question serves. The Centers for Medicare and Medicaid Services (CMS) is the organization that regulates Medicare Advantage plans, and maintains guidelines for dealing with moves and potential disenrollments.

Seniors With Chronic Medical Conditions

Chronic conditions are quite common in seniors, and unlike a passing illness, chronic conditions may require major lifestyle changes and extensive care. Chronic conditions also frequently require heavier reliance on specialists. Original Medicare can provide a basic level of coverage for all chronic conditions, but Medicare Advantage plans can often offer superior care. In a previous section of this article, we discussed the concept of Special Needs Plans for dual eligible and institutionalized seniors. Similar Special Needs Plans, with extensive care coordination and knowledgeable staff, are also regularly created to specifically serve those who have certain chronic conditions. These plans are called Chronic Condition Special Needs Plans (C-SNPs).

A few chronic conditions that are served by C-SNPs:   

• Diabetes
• Heart Failure and other cardiovascular conditions
• Dementia
• Cancer
• Asthma and other respiratory conditions
• Lupus, rheumatoid arthritis, and other autoimmune conditions
• End-Stage Renal Disease (ESRD)
• Epilepsy, ALS, and other neurological disorders

The list above provides merely an indication of common chronic conditions that can be served by a C-SNP. If you have a chronic condition that isn’t on the list, check the official CMS list of possible C-SNP conditions. This list also includes information on some exclusions that apply. Note that some mental illnesses are included in the CMS list, and we provide further information on joining a C-SNP plan specifically for mental illness in the next section of this article.

C-SNP plans can be offered in a few different styles. Insurance companies may choose to create a C-SNP that excludes anyone that does not have a single condition that the company picks from the list. Alternatively, the company can offer a plan that covers a group of related conditions.

Tips for Finding a C-SNP for Your Condition

Look Into Exclusions
The CMS guidelines for qualifying C-SNP conditions are complex in some cases. For example, C-SNPs can be created to serve cancer patients, but patients who have “in-situ status” (not spreading/benign) cancer cells are excluded. If you see a plan listed in your area that is supposed to cover your condition, you may need to ask for specific information about exclusions. Also, note that some plans only serve patients that have two or more related chronic conditions.

Make Sure You Have a Formal Diagnosis
If you are considering a plan for your or your loved ones’ condition, make sure that there are no problems with your diagnosis before you continue. To switch to a C-SNP you’ll need to have documentation of your condition. For example, if you suspect that your loved one has dementia based on behavioral changes, but they have not been formally diagnosed yet, then you’ll need to rule out other problems first and receive a formal diagnosis from the patient’s primary doctor.

Consider Your Current Treatment Success
If you have been receiving an experimental treatment or even a proven treatment that is uncommon and that not all doctors are trained to administer, then consider how switching plans might impact your ability to continue that treatment. Discuss with your current doctors how successful they think your current treatment is and how long they want you to continue it. Find out before you switch plans whether or not you will be able to continue getting this treatment at a reasonable cost.

Seniors With Chronic Mental Health or Behavioral Disorders

According to a 2012 study, about one in five seniors struggle with a mental illness and/or a substance use disorder. In many cases, poor health and problems with mobility, chronic pain, and social isolation can exacerbate underlying mental health and substance abuse issues. Original Medicare, in recognition of mental health struggles in older populations, provides many options for mental healthcare, including depression screenings, wellness visits, psychotherapy, and more. For many patients, the level of mental health care provided by Original Medicare may be enough. However, for seniors who have had serious, chronic difficulty with managing their mental health successfully, turning to a Medicare Advantage Chronic Condition Special Needs Plan (C-SNP) may offer the extra support required.

C-SNPs that are specifically for those with mental illnesses are run in the same basic way as other C-SNPs. These plans cover holistic care (mental and physical), but they have specialists that focus on the needs of patients with mental illness. Below you can see a full list of mental disorders that can be covered by a C-SNP.

Mental health conditions that can be included in C-SNPs: 

• Chronic alcohol/drug dependency
• Bipolar disorder
• Schizophrenia
• Schizoaffective disorder
• Major depressive disorders
• Paranoid disorder

C-SNPs are relatively uncommon, currently accounting for only about 850 of the Medicare Advantage plans on the market in 2020. C-SNPs specifically for mental illness are even rarer, and in 2020 they are only available in California. However, plans enter and exit the market each year, and seniors who could benefit from this kind of C-SNP should check back yearly to see if a relevant plan has been started in their location.

Tips for Finding a C-SNP That Treats Mental Health Disorders

Consult Your Current Care Team
Switching to a C-SNP for your mental healthcare could mean that you’ll need to see new doctors. If you’ve had a good relationship with your mental health providers so far, then you may want to discuss with them what the change in plans will look and feel like for you. If change is difficult for you when it comes to your mental healthcare, then you may want to ask for strategies that you can use to help yourself accept this necessary but major transition of care.

Look Up Your Prescription
For many mental health conditions, it’s vital to consistently take a prescription as directed by your psychiatrist. Quitting or reducing medication without physician oversight can be extremely dangerous. Because access to medication is vital, you’ll want to double-check that the brand and dose that you need will be available to you on the same or better financial terms as it previously was. If changing plans is going to increase your costs, think about whether or not that could put you at risk of missing doses, and make your choice accordingly.

Who Should Consider an Alternative to Medicare Advantage?

There are a few circumstances that can render Medicare Advantage plans either impractical or impossible to sign up for. Read on to learn about quality and accessibility problems that may signal to you that you need to look at Medicare Advantage alternatives.

Seniors Whose Local Options Are Poorly Rated

Medicare has created a rating system so that patients can see how Medicare Advantage plans perform. A plan rating, which is always between one and five stars, can be clearly seen on the right-hand corner of the plan details on the plan finder. According to a recent CMS study, 81% of Medicare Advantage enrollees are in plans that have a rating of four stars or better in 2020. If you’re looking for a plan in your area, and you realize that the only plans available have ratings of three stars or lower, you’ll want to think seriously about whether or not those plans will be valuable to you.

Understanding the star rating system may help you make the call on whether or not a plan with a lackluster rating is worth joining. Below you can see a list of the basic categories that determine a plan’s rating.

Star Rating Categories:

• Staying healthy: screenings, tests, and vaccines 
• Managing chronic conditions
• Member experience with the health plan
• Member complaints and changes in the plan’s performance
• Health plan customer service

Each of the above categories receives its own rating of one to five far ratings, and the categories are totaled to get the overall rating. However, each of the main categories also has its own subpoints. When you are looking at a plan, you can click on the star rating tab and view categories scores as well as the scores of individual items within those categories. Knowing exactly what a plan ranked poorly in and what it ranked well in can help you make the final choice if you’re on the fence.

Seniors Whose Local Networks Are Inconvenient

The majority of Medicare Advantage plans use health networks (a pre-approved list of doctors, hospitals, and other healthcare providers) to keep costs low. If your plan has a health network, then you will most likely get the best price on your healthcare if you use only in-network providers. Most of the time, networks work well for both the insurer and the patient. However, some insurance companies provide networks that are too limiting to really be useful.

If you’re considering a Medicare Advantage plan, contact the insurance company and ask for details on doctors and hospitals in the network. If the only Medicare Advantage plans in your area exclude the healthcare options that are most convenient to you, then you may want to look into other options.

A review of factors that may make a network inconvenient:

• A specific doctor or hospital that you like or need is out-of-network
• You have transportation challenges (you can’t drive, you live far from town, etc.) and the network makes those challenges harder to overcome 
• The size of the network means that patients have to wait too long for appointments
• The network has specialists that treat your conditions, but these specialists don’t use your preferred treatment type (for those who use uncommon or cutting edge treatments)

Seniors Whose Local Options Charge Unreasonable Premiums

The average Medicare Advantage enrollee who gets prescription drug coverage pays just $36 for their health plan premium(s). This is a very reasonable cost, and many seniors would be willing to pay even more than that if it meant quality coverage. However, it’s important to remember that to get Medicare Advantage, seniors also need to pay their Original Medicare premiums. Most seniors will owe a Part B premium of approximately $145 and a Part A premium of $0 in 2020. However, those with high incomes and those who did not pay into the Medicare system via taxes for an extended period of time while they worked may have higher premiums for Parts A or B.

The information below can give you a better understanding of typical premiums so that you can decide if a plan you’re considering is worth its cost.

National Medicare Advantage Premiums Overview:

• The range of Medicare Advantage premiums nationwide is approximately $0-$450
• $0 plan premiums are extremely common 
• The average 2020 premium for Medicare Advantage plans with drug coverage is $29
• On average, Health Maintenance Organizations (HMOs) have the lowest premiums of all available plan types
• Plans with high premiums tend to have low out-of-pocket spending maximums and robust coverage, but this correlation is not guaranteed 
• Some plans charge separate premiums for health coverage and “extras” like drug coverage or dental coverage, while other plans roll all premiums into one

As mentioned above, plan types and coverage levels impact premiums. You can read “What Does Medicare Advantage Cover?” for an overview of coverage standards and an explanation of plan types (for example, HMO, PPO, PFFS, SNP) in Medicare Advantage. Understanding how much coverage different plans provide can help you decide if a premium being offered is worthwhile for you. Be wary of plans that have premiums that are hundreds of dollars above the national average.

Those Who Have Been Diagnosed with ESRD

End-Stage Renal Disease (ESRD, kidney failure) is the final stage of kidney disease in which a patient becomes dependent on dialysis and needs a transplant. Kidney disease leading to ESRD can be caused by a variety of factors including uncontrolled diabetes, high blood pressure, genetic diseases, autoimmune disorders, and more. Those who are diagnosed with ESRD have special opportunities to join Original Medicare even if they otherwise would not be old enough. You can read about how ESRD affects Original Medicare eligibility if you’d like to learn more. Despite the increased likelihood of being eligible for Original Medicare, however, those who have ESRD have unusually limited opportunities to join a Medicare Advantage plan.

Joining a Medicare Advantage plan if you have ESRD can be possible in the following circumstances:

• If there is a C-SNP Medicare Advantage plan in your area that was designed for ESRD patients and that is accepting new members
• If you have already had a successful kidney transplant and you qualify for Medicare based on age or disability 
• If you are already part of a private health plan (possibly offered by your employer) that also runs a Medicare Advantage plan 

Note that if you were already on a Medicare Advantage plan at the time you receive your ESRD diagnosis, then you will most likely be able to stay on that same plan throughout your ESRD treatment.
If any of the above criteria for joining or remaining on a Medicare Advantage plan does not apply to you, then it may not be possible for you to join a Medicare Advantage plan. If you’re in any doubt about your ability to join a plan, it’s best to read more on the official Medicare website and to reach out to a knowledgeable Medicare contact who can discuss the details of your situation with you.

Alternatives to Medicare Advantage

If you can’t join a Medicare Advantage plan, you have other options for getting quality, affordable health coverage that includes more than just the basics of Original Medicare. Each of the alternatives to Medicare Advantage listed below is considered a two-payer method of health coverage (Medicare and the other form of insurance are each called a “payer”). Before you read about alternatives, you can learn the basics about how Medicare works with other forms of insurance on the CMS website.

Alternatives to Medicare Advantage:

• Original Medicare with Medigap: Medigap is supplemental insurance offered by private companies that is designed to cover Medicare deductibles, copays, and coinsurance. Coverage for these items can be partial or full, depending on the plan. Seniors pay a monthly premium in exchange for the Medigap policy covering many of their out-of-pocket expenses. There are several kinds of Medigap plans which are heavily regulated by the federal and state governments. Learn more about plan types here. 
• Original Medicare with Medicaid: For low-income seniors, Medicaid can work with Medicare to provide comprehensive, low-cost support for senior healthcare. Moreover, qualifying for Medicaid often also qualifies seniors for Extra Help (prescription drug assistance) and a variety of other programs. To look into the possibility of Medicaid eligibility, click here. You can also explore benefits.gov to find other forms of medical help based on your location and needs.  
• Original Medicare with Retiree Benefits: Some employers or unions offer retiree benefits to their former employees. If you have the option of using retiree insurance, then this insurance will begin covering some of your health costs after Medicare covers its maximum amount for any given doctor test, service, or care. Medicare’s article on retiree insurance can help you learn more about the rules and common practices of this form of insurance. 
• Original Medicare with VA Benefits: If you are a veteran, you may be eligible for health benefits through Veterans Affairs (VA). To have care covered by VA benefits, you generally need to receive that care at a VA facility. Veterans are encouraged to sign up for both Medicare and VA benefits when they are eligible for both. Together, these two forms of insurance can provide better coverage than either can on its own. Learn more about VA health benefits here.

Frequently Asked Questions