Welcome to Medicare School Daily, where we help you understand Medicare, save money,
avoid mistakes, and above all else, get the most out of your Medicare benefits. As you
probably know, when someone is eligible for Medicare and they're ready to take their Medicare
benefits, there's only two types of insurance that are available. One of those types of
insurance would be a supplemental plan that supplements original Medicare. The other one
is called an advantage plan or a replacement plan. And when you go on Medicare, you have
to choose one or the other. Now, half of all Americans are on supplemental plans and half
are on advantage plans. So one is not better than the other, they're just different. And
today's topic is: I want to address three disadvantages of advantage plans. Now, there are a lot of
advantages to advantage plans, namely two. I'll tell you about the disadvantages in here
just a second. But first off, why do people like advantage plans today? Well, number one,
they like them because of the monthly premiums are very, very low. In fact, on the high side,
someone may pay maybe $49 a month for an advantage plan. But normally
it's more on the low side here, either zero or very low premiums. So that's a nice feature.
The other reason people like Advantage Plan is because all the perks that they throw in
that are typically not available with the supplemental plan.
Those perks would be things like dental benefits, vision benefits, also, sometimes the plans
throw in some hearing benefits, maybe even hearing aids. And then also gym memberships called
silver sneakers. And so these are very nice perks. And so when people look at advantage plans,
sometimes they're very attracted to these particular aspects of their advantage plan.
Ok? And so they buy an advantage plan primarily for that, especially if they're healthy. And
so these are great perks. But we also want to understand there's also some things that
are on the negative side of advantage plans, not trying to frighten you from then not trying
to steer you away from them. But you need to be aware of these disadvantages because
many times agents are honest about these particular disadvantages. So let's go through these disadvantages.
Number one will be networks. If you decide to get a supplemental plan, you have no networks.
Medicare is your network. Any provider that takes Medicare, you can go to that provider.
Any hospital, doctor, specialist. OK? But when it comes to an advantage plan, you will always
have networks. There are two types of networks: HMO and PPO. HMO networks are typically
a little smaller than PPO. HMO have certain restrictions that PPO may not,
such as referrals required, and you can't go out of the network.
But anytime you have an advantage plan, you have to make sure that your providers are going
to be in the network, that you can go to the doctor that you choose or the specialist you
choose; a hospital that you choose. Now, listen, there's no doctor or hospital or specialists
that's going to take all of these plans, at all. Some will take an HMO. Some will take a PPO.
And sometimes they'll take both. But you have to make sure your providers are within the
network because you have these network restrictions. The second disadvantage would be pre-certifications,
pre-certification. What's that mean? That means that the doctor has ordered an MRI
or maybe a CAT scan or maybe is saying that you need a hip replacement or knee replacement
and that is going to have to be pre-certified. Now, every service that you have on the advantage
plan does not have to be pre-certified. You can go to your primary care doctor. You can go
to a specialist. There are lots of things you can do without a pre-cert, but there are sometimes
a pre-certification will be required on your advantage plan. Now, if you stay on original
Medicare with the supplemental plan, there's never a pre-certification. Medicare and your
doctor make all the rules. Your doctor has the final say so. When you have an advantage
plan on certain services, your doctor does not have the final say so.
If doc is suggesting something that requires a pre-certification, they're going to have
to call the advantage company and they're going to get that pre-approved. Just recently
we had a lady that was needing a hip replacement. Total hip replacement is what doctor suggested.
She was on advantage plan, and the advantage plan said, no, we're not going to pay for a full
hip replacement. You can use a rod instead. We had a lady recently who was also needing
hip replacement; advantage plan said you must go to therapy for 9 months. After that,
if you still need a hip replacement then we'll discuss that. Had someone again recently,
needed an MRI on his back. Having chronic back pain, they couldn't figure out what it
is, orders the MRI, and the advantage plan said no, go to therapy for three weeks. Call us back after that.
And so the whole point is they have a say so in your health care; it's not just your
doctor that make the final decisions. The plan also has some say so in what is going
to happen with your health care. OK? A some people are just annoyed by that, so you need
to be aware. Then lastly, switching plans. Now, every year, Medicare has an open
enrollment period. This is October 15th to December 7th.
And many people think because we have this open enrollment period, that folks can switch
plans and change and just do whatever they want without any rules. And that's not true.
If you were on an advantage plan and let's say that you would like to switch to a supplemental
plan and get off of that advantage plan. Do you realize, folks, that after you have been
on advantage plan one year, anytime after one year, if you want to make that switch,
you have to be approved by that insurance company to make the switch. Meaning you are going to
have to go through underwriting, the insurance company's going to ask you 20 to 25 health
questions. They're going to check your medications and see what you're being treated for. And
they're also going to possibly get a statement from your doctor. We call the attending physician
statement. So you may have to get that statement from your doc. And so the whole point is an
underwriter is going to have to approve you to make that switch. So, so many people think
they can just switch and do whatever they want. But after you've been an advantage plan one
year, to make the switch to supplemental plan, you'll have to medically qualify. So these
are some features that you have to live with. Yes, there's some nice perks and the premium
is very low. But you also have to be comfortable with these
situations as well if you decide to choose a Medicare Advantage plan for your coverage.
Thanks so much for watching.