Myths about Medicare Advantage

Created date

September 29th, 2017
Senior researching on a laptop.

Senior researching on a laptop.

Beginning in the 1970s, Medicare beneficiaries could choose to receive benefits via private health insurance plans. Today, this program is known as Medicare Advantage, or Part C.

Practically any health insurance plan can be confusing, and Medicare Advantage (MA) is no exception. Following are some misconceptions about Medicare Advantage, along with explanations about how these programs work.  

Misconception #1:
It costs too much and you get fewer benefits than with Original Medicare.  

It is important to know exactly what you are getting for your money.

All Medicare Advantage plans are required to offer the same benefits as Original Medicare (Medicare Part A and Part B). Many Medicare Advantage plans include prescription coverage (Part D), and some plans may offer additional benefits and features. 

For example, some plans under Erickson Advantage—a Medicare Advantage plan exclusively for residents of Erickson Living communities—offer preventive dental services, routine podiatry care, falls prevention, and eyeglass and hearing aid coverage. In certain Erickson Advantage plans, transportation to medical appointments is available (up to 12 round trips or 24 one-way trips per year to and from in-network medical appointments).

The Erickson Advantage plan additionally provides an on-site nurse care coordinator who assists members in navigating the health care system when needed and guiding members for managing their chronic illnesses and staying healthy.  Member service staff also is available to assist with scheduling of appointments, coordinating transportation, and answering any billing questions. 

Another important consideration between Original Medicare and some Medicare Advantage plans is the hospital stay requirement before you are covered for a skilled nursing stay. In the current health care system, if you have Original Medicare and have to be admitted to a skilled nursing facility after a hospitalization, you may have to pay for it out-of-pocket if you are not admitted to the hospital as an “inpatient” for three days before going to the skilled nursing facility. That’s because Original Medicare beneficiaries must be classified as a “hospital inpatient” for three days beforehand to receive coverage for a skilled nursing stay. 

In some Medicare Advantage plans such as Erickson Advantage, the three-day hospital inpatient-stay requirement is waived.  In fact, members who have a medically necessary need may go to a skilled facility even if they haven’t been admitted to a hospital. A skilled nursing facility stay can be necessary for many reasons, including a stroke, joint replacement, a chronic infection, or wound care. This type of benefit could potentially save you a lot of money, especially if you do not have a qualifying three-day “inpatient hospital” stay. A 2016 Genworth Financial survey showed that in the U.S., the median cost for a 30-day skilled nursing facility stay is about $7,000.

Erickson Advantage Health Resource Managers are available for residents who would like to learn more about the Erickson Advantage plan or to provide a comparison review of your health insurance plan and how it works. 

Misconception #2:
You cannot choose your doctors.

Medicare Advantage plans were originally structured primarily as Health Maintenance Organization (HMO) plans. “HMO” has become a controversial term in health care, largely because of the restrictions requiring authorizations to see providers in the network from your primary care doctors.    

Today, however, Medicare Advantage plans can be structured in several ways besides HMOs. In a Point of Service plan (POS), you can generally get your care from any provider within the network without a referral from your primary care doctor. If you want to see a provider outside the network, you may have higher copay for the out-of-network benefit. Generally, you can receive care from any out-of-network provider who accepts Medicare.   

Erickson Advantage is an HMO-POS plan, which allows members to receive care for specialists listed in the network without a referral. Erickson Advantage also provides a benefit for members to receive care from providers who accept Medicare outside the network, though higher copay may be incurred. 

Misconception #3:
Enrollment in Medicare Advantage plans is declining.

In fact, the opposite is true. According to the Kaiser Family Foundation, enrollment in Medicare Advantage plans has been increasing over the past decade. Medicare Advantage enrollment has tripled since 2004, such that 33% of all Medicare enrollees are now in a Medicare Advantage plan in 2017.

Plans are insured through UnitedHealthcare Insurance Company or one if its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. 

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change on January 1 of each year. 

The provider network may change at any time. You will receive notice when necessary. For information on all Medicare insurance plans, call 1-800-MEDICARE, (TTY 1-877-486-2048), 24 hours a day/7 days a week.