This article is the second of a series designed to highlight the pros and cons of Medicare Advantage plans. The Author is a former hospital administrator who spent over ten years as Executive Director of a state-wide industry group dedicated to home health & hospice prior to becoming an administrator for a home health agency. The views expressed here are intended to be factual, but I will give you my honest opinion as well.


Pros and Cons of Medicare Advantage Plans

Pros and Cons of Medicare Advantage Plans


Medicare Advantage Enrollees Can Still Switch to Original Medicare

– Todd Stallings, FACHE

Disclaimer: I write this as a provider of home health services to Medicare and Medicare Advantage patients. I readily admit that I have a biased view of Medicare Advantage because it has made it harder to deliver high-quality care that patients need and yes, it is less financially beneficial for my home health agency than original Medicare.


Many Seniors and Medicare beneficiaries have chosen to switch from their original Medicare (I call it “traditional” Medicare) to a Medicare Advantage plan sponsored by a commercial insurance company. These can be HMO or PPO plans and while they do not replace Medicare – an enrollee still “has Medicare” – we often refer to them as “Medicare Replacement” plans because they DO replace the usual workings of Medicare with something that works like commercial managed care. Let’s face it – Medicare Advantage is Managed Care. If you want to read my previous post about Medicare Advantage, click here.


Medicare enrollees who have joined a Medicare Advantage plan have an additional Open Enrollment Period during which they can switch back to original Medicare or to a different Medicare Advantage plan. This Open enrollment runs from January 1st through March 31st and is only for those already in a Medicare Advantage Plan.


Here are some examples of why a Medicare beneficiary might wish to switch back to original Medicare:


Network limitations: A friend of mine recently learned she needs a major surgery that is not routine. Her condition requires a top-flight surgeon who specializes in her condition. Unfortunately, her plan was an HMO and did not cover out-of-network providers and the top surgeon in the area does not contract with Medicare Advantage plans. My friend’s plan directory contained a handful of doctors with his specialty. One of those had closed their practice, one had moved his practice out of the area, and one that she contacted informed her that he did not do that procedure. During Open Enrollment in the Fall, she switched to another Medicare Advantage plan that will pay 60% for out-of-network in order to use the surgeon that she wanted. That will bring her share down to around $7500. However, this top surgeon does participate with original Medicare. Even with a deductible from Medicare, she stands to get the care she needs without bankrupting her if she switches back to original Medicare.


Utilization “Management”: Remember, Medicare Advantage is Managed Care. Perhaps more accurate, Medicare Advantage is Managed Cost – for the insurance company. Every dollar they save on your care falls to the bottom line. Utilization Management as it is currently practiced for home health seems to focus on limiting visits and thus limiting the cost of care. Note this NOT the same thing as assuring that the appropriate care is delivered, just less. Home health agencies must obtain authorization to make visits to the patient in small quantities – often as little as one visit is approved. Home health must then go back time and time again to justify continuing to care for the patient. This delays care and increases the risk of hospitalization.


Misinformed sales representatives: I maintained my health insurance agent license for several years. During that time, I received training on sales of Medicare Advantage and supplements. I can tell you the amount these hardworking agents receive for each policy they sell is small. In order to make a living, they need to “write” many policies to survive. I never met a licensed agent who intended to mislead a Senior to sell a policy. However, I met many who had a limited understanding of the consequences of leaving original Medicare for Medicare Advantage. Their job is to be an agent of the insurance company and meet the government requirements – not be your personal advisor and advocate. They are great at showing the benefits of a Medicare Advantage Plan, just not so great at discussing the drawbacks.


How to switch from Medicare Advantage to Original Medicare: The Medicare Advantage Open Enrollment Period runs January – March. If you believe you made a mistake in signing up for Medicare Advantage or you are simply not happy with the coverage and benefits, you may call 1-800-MEDICARE (1-800-633-4227) and request to go back to Original Medicare.


Next: In my next post, I’ll discuss under what circumstances you can make the change outside the Open Enrollment Period. This is harder to do, and you must meet certain conditions.



Here’s What You Need to Know About Medicare Advantage Open Enrollment Motley Fool
Medicare Open Enrollment FAQ’s Kaiser Family Foundation
Joining a Health or Drug