Medicare Advantage also restricts full coverage only to doctors, hospitals and pharmacies within their networks; if patients go outside the network, they face higher costs or may have to pay entirely out of pocket. In-network providers change frequently, and it can be challenging to ascertain which ones a plan includes.
Except for emergency or urgent care, Medicare Advantage coverage may not extend outside beneficiaries’ county or state. “If you’re in Albany, you may not be able to get care in New York City,” Dr. Jacobson said. Advantage plans also often require preauthorization from the insurer for services and drugs.
With traditional Medicare, “you can see any provider you want to at any time, without getting prior approval,” Dr. Jacobson said. It’s accepted nationally. But factoring in a private Medigap policy and a separate Part D plan sometimes pushes overall costs higher.
Still, a recent Commonwealth Fund analysis found that traditional Medicare and Advantage plans (excluding special needs plans) now attract similar populations in terms of demographics and health, with high rates of satisfaction in both groups (though both reported waiting more than a month for a doctor’s appointment).
Advantage beneficiaries are more likely to receive some care management services, such as a review of their medications, the study found. But when it comes to patients’ health, “it doesn’t seem to change the outcomes much,” Dr. Jacobson said, because hospitalization and emergency room use were roughly the same for both groups.
That raises the question of whether the federal government should continue paying Advantage plans 4 percent more per beneficiary than it pays for those in traditional Medicare. Everyone who pays a Part B premium, which is almost every beneficiary, winds up subsidizing that higher cost.
But for now, it’s open enrollment season. SHIP programs in every state, with 12,500 trained team members, represent the best source of unbiased information and work with more than 2.5 million people each year.