To Tell The Truth

Debunking myths about Medicare Advantage plans

Thinking about enrolling in a Medicare Advantage plan but concerned it may be less advantageous than the name implies? Medicare Advantage (MA) plans are a viable alternative to Original Medicare for those who are looking for comprehensive health care coverage.

Increasingly, Medicare beneficiaries are gravitating toward MA plans. A report from the Centers for Medicare & Medicaid Services shows MA provides coverage for just over half of all eligible Medicare beneficiaries. And a survey from the Commonwealth Fund reports 96% of MA members said their Medicare coverage met their expectations.

While MA plans may not be for everyone, they are certainly a beneficial option for many. Torrance Memorial IPA—a multispecialty physician network serving the South Bay community since 1983—contracts with several major MA plans and provides no-cost consultations from licensed insurance agents.

So why do MA plans occasionally get a bad rap in the first place? Let’s take a deep dive into nine of the most common myths about MA plans, and explore myth-busting evidence to the contrary.

MYTH: I’ll have a problem finding and using in-network providers.

TRUTH: Medicare Advantage plans do use provider networks, but so do many health insurance plans. Talk with a trusted insurance broker about the size and quality of the medical groups available with your plan. You may have a higher share of cost or not be covered if you see an out-of-network doctor, so be sure your doctor is covered on the plan you choose if you need regular treatment from a specialist. Torrance Memorial IPA’s network includes more than 500 primary care and specialists.

MYTH: I’ll need a referral from my primary care physician every time I see a specialist.

TRUTH: This is typically true for most MA plans, but referrals to a specialist typically don’t take very long. And Torrance Memorial IPA allows self-referral to eight categories of specialists, including cardiology, dermatology, gastroenterology, podiatry and behavioral health.

MYTH: There are complicated prior authorization requirements.

TRUTH: MA plans can require members to get prior authorization before receiving a covered service. Your medical group or health plan typically must give or deny approval within three to five days. If you need an urgent appointment for a service requiring prior authorization, that urgency reduces the wait to 24 to 48 hours. Ask a trusted insurance broker about a plan’s rules around prior authorization before you enroll.

MYTH: Good doctors don’t accept MA plans.

TRUTH: Very reputable doctors, hospitals and medical groups choose to be aligned with MA plans, including UCLA Health, Keck Medicine of USC, Torrance Memorial IPA, Scripps Health and Providence, just to name a few.

MYTH: There are long wait times for me to get an appointment.

TRUTH: Long wait times for an appointment can be a problem with any insurance plan. Ask your agent which doctors are experiencing longer wait times for appointments. Sometimes the wait times are shorter with newer physicians. Torrance Memorial IPA recruits new physicians throughout the year to help with access to care.

MYTH: If I need care while traveling outside the United States, it will not be covered.

TRUTH: In most cases, MA plans offer a more robust benefit for foreign travel compared to a Medigap supplemental plan, and in most situations Original Medicare alone doesn’t cover medical costs outside the country at all. Most MA plans allow ER/urgent care anywhere in the U.S. and out of the country as well. These benefits for many MA plans are unlimited and do not require a share of cost or deductible.

MYTH: A procedure I need may not be approved or covered, while Original Medicare covers everything.

TRUTH: Both Original Medicare and MA have a “medically necessary” requirement. When a service is medically necessary, the MA plan will not deny coverage as long as you seek care from providers in the plan’s network.

MYTH: I can only make changes to my Medicare insurance during the annual enrollment period.

TRUTH: There are a variety of enrollment periods throughout the year. If you are in an MA plan, you can change your primary care provider and/or medical group at any time. The Annual Election Period (October 15 to December 7) is the most common time to change plans. However, during the Open Enrollment Period from January 1 through March 31 you can change to another MA plan or back to Original Medicare. You can also change if you move out of the county or to a different state. Other situations—such as having a chronic condition or being impacted by a natural disaster—may allow you to switch plans. Check with a Medicare licensed broker to learn more.

MYTH: Medicare Advantage plans are expensive.

TRUTH: MA is the only Medicare plan that limits how much you must pay annually, called the maximum out-of-pocket (MOOP). Many MA plans have $0 premiums and feature benefits not offered by Original Medicare, such as prescription drug coverage, dental, vision and hearing aids.

Get the facts about Medicare Advantage. Torrance Memorial IPA will connect you with a trusted and licensed Medicare insurance agent who will help you explore your options and enroll in the plan that’s right for you.

For more information call Torrance Memorial IPA at 310-517-7239, or licensed independent agents Vince Kelly at 310-625-1837 or Rose Straub at 310-715-2300. You can also attend Torrance Memorial IPA’s complimentary Medicare 101 lectures (TorranceMemorialIPA.org/medicare101) for more information.