By Elizabeth O'Brien
October 4, 2019

The Trump Administration has actively promoted Medicare Advantage, the privately managed alternative to Original Medicare that has become increasingly popular with beneficiaries in recent years. The President spoke Thursday about improving the program and protecting patients’ access to their doctors in a speech at The Villages, a large retirement community in central Florida.

Trump told residents that his administration was working to “ensure access to the doctors of your choice.” Here’s the thing, though: many Medicare Advantage plans are HMOs that come with a network of participating doctors and hospitals. Nearly two-thirds (62%) of Medicare Advantage enrollees are in HMOs, according to the Kaiser Family Foundation. Some of these HMO networks can be restrictive, with relatively few participating hospitals and specialists available to their enrollees.

Original Medicare offers much broader access to doctors, because the program doesn’t have a network: beneficiaries can visit any doctor, specialist, hospital or urgent care center that accepts Medicare, anywhere in the country. Original Medicare is administered by the federal government, whereas Medicare Advantage plans are managed by private health plans that contract with the government to provide Part B outpatient services and Part A hospitalization coverage.

Medicare Advantage plans have grown in popularity in recent years, with about 34% of Medicare beneficiaries currently enrolled, according to the Kaiser Family Foundation. One reason for this is because these plans sometimes cover services that Original Medicare doesn’t, such as gym memberships and vision and dental benefits. Starting next year, benefits in many Medicare Advantage plans will expand to include transportation, meal delivery and other services to qualifying enrollees.

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The trade-off for these extra perks is a potentially limited choice of doctors. Networks vary by plan, and it’s very important to understand which doctors you’d have access to if you opt for Medicare Advantage.

One reason you might opt to switch to a new plan, or to switch out of Medicare Advantage altogether and into Original Medicare, is if you receive a serious diagnosis and want to see a specialist your plan wouldn’t pay for.

Medicare’s annual open enrollment period, which runs from Oct. 15 to Dec. 7, offers you the option to make a switch and change your coverage for next year. But there’s a big caveat to keep in mind: If you’re switching to Original Medicare and want to buy a Medigap supplement plan, keep in mind that these plans are medically underwritten outside of certain limited circumstances.

That means that insurers look at your health history when you apply and can charge you more or even deny you coverage based on pre-existing conditions. Cancer and diabetes are examples of conditions that could be grounds for denial (each insurer has different criteria). If you’re denied coverage, you’d still have Original Medicare, but you’d need to pay about 20% of your care costs under Part B, and that amount is uncapped. Research your options and make sure you’re comfortable with them before you quit your existing plan.

 

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