What Is Medicare Advantage? Is It Better Than Regular Medicare?

Medicare Advantage Offers More, But At A Higher Cost To Government

What is Medicare Advantage, and should I enroll in it? Is regular Medicare coverage just as good? What are the differences? Medicare Part C is the portion of Medicare that covers Medicare Advantage programs. This article will try to explain it in layman's terms, ignoring the complex and concentrating on the practical. Many do not understand the different options that seniors have offered to them, so I will try to make this as simple as possible. Medicare Advantage, for the patient, can be a welcome alternative to traditional Medicare, but it does have some problems. It is not perfect and does cost more money for the government to offer.

The federal government pays private insurance companies over $1,000 per year for each of the 11 million current enrollees. This payment is over and above the normal costs of Medicare that are paid to the companies. It is a bonus, if you will. Eleven billion dollars per year is a pretty big bonus. What do seniors get for the bonus? Depending on the plan they enroll in, they can get plenty! Some plans offer dental coverage, comprehensive vision coverage, acupuncture and chiropractic services, while still others offer gym memberships. In other cases, not so much. The cost of Medicare Advantage to the beneficiary is generally less than traditional Medicare coverage. Instead of the usual 80/20 split as in Medicare Part B (outpatient services), there is often a $5.00 to $20.00 copay for office visits. That alone usually saves money.

Medicare Advantage HMO's

Most of the 11 million Advantage enrollees are covered under HMO plans. The plans mirror those offered on the commercial market. Secure Horizons, Kaiser Advantage, Scan are just a few of the plans in existence. Once enrolled, a Medicare recipient has no need to buy a supplemental insurance policy.

In order to enroll in a Medicare Advantage plan, the beneficiary must first enroll in Medicare Part A, Part B and Part D. Once that enrollment is complete, enrollment in a Medicare Advantage plan is possible.

Since these plans are generally mirror images of the commercial products, the problems are the same, or can be. Depending upon the choice of network and primary care physician, authorizations can take time. In virtually all cases, the primary care physician is the gatekeeper. He or she will determine what specialists are seen and he or she will also coordinate what testing is done. The Medicare recipient also gives up the right to see any or all of the doctors they choose. Their complete care regimen is controlled by their primary care physician.

With Medicare Advantage, you cannot go to doctor after doctor for the same problem. You will not be getting a CT scan ordered by each doctor you see. Your care will be highly coordinated and utilization will be monitored.

Why Write About This Now?

With the Ryan budget plan, now the GOP budget plan, being adopted by the entire right side of the aisle, Medicare Advantage programs come front and center. They are run by private insurance companies, and although President Obama has been accused by the GOP and others who are uninformed of cutting $500 Billion dollars from Medicare, those cuts came mostly from attempts to rein in and discontinue the government bonuses paid to private insurers for Medicare Advantage. None of that $500 Billion dollars came from cuts to services covered by the original Medicare plan. You may have heard different, but what you heard was a lie!

Perhaps the most clearly written explanation of the cuts in the Affordable Health Care Act come from another hubber on this site: Deni Edwards. The link to her comprehensive article is: http://hubpages.com/hub/healthcarereformandmedicarecutsandbenefits .

It is a great article and should be read by all!

Finally, if I was a Medicare-eligible senior, I would enroll in a Medicare Advantage program in a hot minute. It would save me money. BUT, and that is a capital BUT, I have worked my entire life in the health care field. I know which plans are good and I also know my way around the private insurance maze. I know how to fight delays in authorizations; I know how to fight claims denials. I do not consider myself a lay person.

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Comments 15 comments

junko profile image

junko 5 years ago

I got a little time before I'm ready for medicare, but not enough time to forget this hub. vote up and useful


Nan Mynatt profile image

Nan Mynatt 5 years ago from Illinois

Thanks for the education on medicare. It's a runnaway program right now.


Jillian Barclay profile image

Jillian Barclay 5 years ago from California, USA Author

Thanks, junko. Medicare Advantage is a big money maker for the private insurance companies. My point in writing this was to make sure that the people who still think that Obamacare, as it is called, tried to defund Medicare actually know the truth.

Dear Nan,

Medicare is run away due, in large part, to so much duplication. I remember my grandmother, who had nerve damage. She would use her Medicare and go from one doctor to the next, getting a CT from each, every few months, at $1500 a pop, plus the neurologist's bill. They all told her the same thing, that there was nothing they could do to help her. She would then search out another doctor who ordered the same testing.

Her eyesight was also failing and her physician was billing Medicare for laser surgery every 6 weeks at $5000.00 each time. I would tell her that laser surgery that often was not necessary. Sure enough, the doctor was arrested and found guilty of over $27 million dollars in fraudulent billing. Those are some of the reasons that Medicare is a run away program. There is little monitoring and even less as far as utilization review. It is a mess, but costs can be cut without cutting benefits. The secret is actually getting the correct people in there to overhaul the utilzation and duplication.

My grandmother was healthy, never in the hospital, and ran up over $80,000 in Medicare costs for just one year. Multiply that by numerous patients and what do you get? A helluva lot of unnecessary spending...


PETER LUMETTA profile image

PETER LUMETTA 5 years ago from KENAI, ALAKSA

Thanks Jillian for reminding me that I could join that club if I was back in the states. Someday I may take advantage of those programs if I do I'll have to take a refresher course from you. Peter


Jillian Barclay profile image

Jillian Barclay 5 years ago from California, USA Author

You are welcome, as always Peter! And if you come back, I will gladly help you through the maze.

Anytime!


cathylynn99 profile image

cathylynn99 5 years ago from northeastern US

i'm in a medicare advantage plan. it includes part D, so i didn't need to sign up for D separately.

the included free YMCA membership is great. they're putting their money where their mouth is on prevention.


Jillian Barclay profile image

Jillian Barclay 5 years ago from California, USA Author

Dear Cathylynn,

If I had Medicare, I would sign up for Medicare Advantage in a moment! It really is the best coverage for the money.

When I worked as a full-time patient advocate, all of my clients were seniors, and all of them had difficulty with their Advantage plans. Most of them were not even aware of the benefits they had and did not know how to access them. The problem usually centered around their choice of a PCP. The right PCP is the key! You have a good one, as do I. Always choose the internist!

Sadly, not everyone is as savvy as you. I used to give free seminars and they would line up around the block. Just a little bit of education was all most of them needed. There are still thousands and thousands that do not understand their policies. Especially when it comes to the pre-authorization process.

Thanks, Cathylynn.


amillar profile image

amillar 5 years ago from Scotland, UK

The UK still has the NHS, but it's constantly under threat. I think that the more diverse the 'plans', the more diverse the schemes.


Jillian Barclay profile image

Jillian Barclay 5 years ago from California, USA Author

Oh, My God! Amillar, I believe you have just hit the nail on the head, as they say! I never thought of it that way, but you may just be right. Chalk one up for single payer...


Fay Paxton 5 years ago

Excellent information as usual. Medicare Advantage and the prescription drug plan were Bush's gifts to private industry. If only people could understand that Medicare is a problem because of healthcare costs, we could get somewhere in this debate. As always, you make an excellent contribution to helping people better understand.

up/very useful and awesome


Jillian Barclay profile image

Jillian Barclay 5 years ago from California, USA Author

Dear Fay,

So true! The cost of medical care as a whole is rising faster than every other sector. Of course, Medicare is a part of that, but not the cause. If the government allowed competition for drugs and outcome-oriented payment to providers, costs for Medicare would decrease, especially when added to serious detection and prosecution for fraudulent billing. Fraudulent billing is not just billing for services never provided. Upcoding is probably (in my experience) the best place to start enforcement. But most are not serious about stopping the abuses. They are too tied to the drug companies, the hospitals and the AMA.

Ryan's plan makes no attempt to lower costs. He is trying to give more gifts to the insurance companies. It is a scheme designed to enrich the insurance companies and all of the other regular players...while bankrupting the people Medicare was designed to protect.


Terry.Hirneisen profile image

Terry.Hirneisen 5 years ago from Shenandoah Valley

I like my regular medicare. I had an HMO when I worked and had to ask permission to see a specialist. Now if I want to see a dermatologist or a urologist I make an appointment. I am not sure why I would be interested in Medicare Advantage. I do have part D but I don't take any drugs so that is a looser right now for me. I just have it in case I do need some expensive drug someday.


Jillian Barclay profile image

Jillian Barclay 5 years ago from California, USA Author

Hi, Terry,

People who have many health issues like Medicare Advantage, because it keeps their costs down. The authorization process with Medicare Advantage is the same as with commercial HMO's.

The private companies that participate are on top of utilization. They allow very little duplication. A good PCP is the secret to getting authorizations through quickly.

In your case, you are currently healthy, so of course, find little need for the Advantage program. What I tried to make the big issue here is the BONUS that the govt pays. It is alot of money and the bonus is one of the things that the Affordable Care Act abolishes.


Dave Ketterer 5 years ago

I am trying to sort out all the terms regarding Medicare. Can you explain if "basic", "regular" and "traditional" Medicare are the same?


Jillian Barclay profile image

Jillian Barclay 5 years ago from California, USA Author

Basic, regular and traditional Medicare are all the same. part A is inptn care, which is automatic.The three you speak of are the 80/20 plan for outptn services(Part B), to which most people, if they can afford it, buy a supplemental policy to help with the share of cost. And then, you would also enroll in and pay for Part D, the prescription coverage.

Medicare Advantage, in my opinion is the cheaper and most comprehensive way to go. You don't need to purchase a supplemental policy and instead of paying 20% of your outptn care, you pay a co-pay when you see your doctor- you also pay a co-pay for your meds.

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