Is Medicare Advantage Right for You?

In 2020, over 60 million people in the U.S. were enrolled in either original Medicare Advantage. Medicare Open Enrollment Period (OEP) runs every year, from October 15 to December 7.

During this period, it enrollees aged 65 or above can switch between original Medicare and Medicare Advantage, or may choose to stick with Medicare alongside a different plan. The new coverage starts January 1.

Unlike original Medicare, which is federally run health insurance, Advantage plans are offered by approved private health insurance companies.

Ten years ago, around one-fourth of beneficiaries opted for Advantage plan, but in 2021, over 40% of beneficiaries chose to have their coverage via Advantage plan.

A major reason behind the popularity of MA plans is that they usually have lower premiums and they come with additional benefits.

Having said that, TX Medicare Advantage plans may cost more in the long run, depending on a patient’s health-specific needs.

In 2022, an average beneficiary has 39 plans to select from in their local market, so making the right choice is difficult.

Therefore, it is important to know what to look for and how Medicare Advantage plans work, particularly in comparison to original Medicare.

Offers Multiple Medicare Services

Medicare Advantage (MA) is a type of managed care. These health maintenance organization or preferred provider plans limits enrollees to just in-network hospitals and physicians.

In contract with Medicare, private insurers offer Medicare Advantage plans in Texas that must provide at least the same benefits as offered under Part A and Part B, covering hospital stays and physician visits, respectively.

Many people think that with an MA plan, they don’t need to pay Part B premiums, but that’s not true. You pay premiums for your MA plan as well as Part B to receive your Parts A and B benefits via your MA plan. Part A coverage is, however, usually free.

If you are not insured by a qualifying health plan via your own employer or your spouse’s employer, you must enroll in Part A and Part B once you turn 65.

Failing to do so may lead to penalties. But, you are not required to enroll in an MA plan or Medigap.

Incidentally, the additional insurance is broadly deemed essential since Part A covers hospital-related expenses only for the first 60 days of hospitalization and that too after a deductible (which was $1,484 in 2021).

Generally, Part B pays just 80% of outpatient expenses once you meet your deductible (which was $203 in 2021), eventually leaving you on the hook for the remaining expenses with no limit on out-of-pocket costs.

Another way to get your benefits is via a Medicare Advantage plan in Texas. These plans pick up where Part A and Part B cut off in order to restrict your out-of-pocket costs.

In 2021, MA enrollees, on average, paid a maximum of around $5,100 for in-network only care, and nearly $9,200 for both in- and out-of-network care, as per the Kaiser Family Foundation.

The average monthly premium for an MA plan, along with prescription drug coverage, in 2021 was $21, and nearly 65% of those plans had no monthly premium.

Most Advantage plans club Part A, Part B, and Part D (prescription drug plan) into a single plan.Original Medicare enrollees usually buy three separate plans: Part B, Part D, and Medigap – but, these costs may add up.

Medigap plans, sold by private health insurers have a monthly premium, over and above the premiums for Part B and Part D.

As per eHealth, in 2020, Medigap monthly premiums ranged from $134 for people aged 65 to 70, to $205 for people 80 and older.

Since Medicare Advantage plans in San Antonio, TX do not involve any medical underwriting, no insurance company can reject you. Most MA plans offer additional benefits, including vision, hearing, and dental coverage that are not offered under original Medicare.

If you choose to enroll in original Medicare, you may require buying other plans to get vision, dental, and hearing coverage. Some MA plans also come with free gym membership and/or transportation costs of visiting your doctor.

Remember that you do get a chance to change your MA plan, but only once in a year. it’s enrollment period runs from January 1 to March 31, and the coverage begins July 1.

People, who have missed enrolling after turning 65 and also do not qualify for a special enrollment period, can enroll in Part A and Part B.

Enrollees of MA plans can also switch to a different MA plan or revert to original Medicare in San Antonio, Texas during this period.

The Downsides of Medicare Advantage Plans in Texas

Out-of-pocket expenses are usually higher for Medicare Advantage, compared to original Medicare clubbed with a Medigap plan. This is true even when, unlike MA plans, there is no out-of-pocket maximums for most Medigap.

A Kaiser Family Foundation report showed that around 19% of MA beneficiaries faced problems in covering costs in 2018, vs. 12% of original Medicare enrollees with a Medigap plan.

The Kaiser study highlighted the difficulty with MA’s cost-sharing requirements like copays for inpatient services and coinsurance for prescription drugs – costs that Supplement plans often cover.

Medicare Advantage plans often require a referral from your primary physician to see a specialist, and you pay significantly more when you use an out-of-network hospital or doctor. On the contrary, almost every hospital or physician accepts original Medicare.

Moreover, you coverage may change every year, in line with the differences described in your MA plan’s yearly “notice of change.”

Copays and premiums may increase, and several medicines may be excluded from coverage. Your primary physician may no longer be in your plan’s network next year. However, the coverage offered by Supplement plans usually remains the same next year.

While you can switch from an MA plan back to original Medicare in San Antonio, Texas, along with a Medigap plan, you might be underinsured temporarily.

The non-requirement of medical underwriting for Medigap is only applicable for the first six months after your enrollment in Part B. Other time, such as after enrolling in an MA plan, a Medigap insurance company may ask for a higher premium or put a waiting period.

Shopping for a Medicare Advantage Plan in Texas

To decide between a Medicare Plan and original Medicare with a Medigap plan, you should ask yourself this question – “What do I prefer: a higher premium or a higher out-of-pocket costs?

If you choose to enroll in Advantage plan, keep aside the money you would save on premiums to pay for out-of-pocket expenses in future.

The Medicare.gov website offers a tool to help you price varied Medicare Advantage, Medigap and Part D plans, on the basis of your location and personal details.

The tool aids in estimating the expense of your medications for every MA plan while listing the copays, monthly premiums, and maximum out-of-pocket costs. Information on extra benefits like dental or vision care, are also offered.

You can also visit any approved insurance company’s website to check whether or not your preferred physicians are in the network of the MA plan you are looking to buy.

You may also contact your preferred doctor to check if they offer services under your plan’s network. It’s also a good idea to check the plan’s network for your preferred long-term care facility or hospital.

A licensed insurance broker can help you navigate this seemingly cumbersome process. It is best to contact an independent local agents near you to get unbiased advice on different plans available in your area. 

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