Medicare Advantage Plans, also known as Part C, are health plans offered by private companies that provide all the benefits of Original Medicare (Part A and Part B) and often include prescription drug coverage (Part D) and other extra benefits. Medicare Advantage Plans can be a convenient and cost-effective option for many people with Medicare, but they may not be the best fit for everyone.
How do you know if you are in the wrong Medicare Advantage Plan? Here are some signs that you may want to consider switching to a different plan or going back to Original Medicare:
- You are paying too much for your plan. Medicare Advantage Plans have different premiums, deductibles, copayments, and coinsurance amounts that can vary depending on the plan and the services you use. You may be able to find a plan that offers similar or better coverage at a lower cost, especially if you qualify for financial assistance such as Extra Help or Medicare Savings Programs. You can compare plans and costs using the Medicare Plan Finder tool or by contacting your State Health Insurance Assistance Program (SHIP).
- You are not satisfied with your plan’s network of providers. Medicare Advantage Plans have their own networks of doctors, hospitals, and other health care providers that you must use to get the full benefits of your plan. If you go outside the network, you may have to pay more or get no coverage at all. You may be unhappy with your plan’s network if you have trouble finding or accessing providers that meet your needs, preferences, and location. You may also want to switch plans if your current providers leave the network or stop accepting your plan.
- You are not getting the care or services you need. Medicare Advantage Plans must cover all the services that Original Medicare covers, but they may have different rules, restrictions, and prior authorization requirements that affect how and when you get those services. For example, some plans may require you to get a referral from your primary care provider before seeing a specialist, or they may limit the number of visits or days of coverage for certain services. You may be in the wrong plan if you feel that your plan is denying, delaying, or limiting the care or services you need or want. You have the right to appeal any decision your plan makes about your coverage, but you may also want to look for a plan that has fewer or more flexible rules.
- You are not happy with your plan’s quality or customer service. Medicare Advantage Plans are rated by the Centers for Medicare & Medicaid Services (CMS) based on their performance on various measures of quality, such as how well they provide preventive care, manage chronic conditions, and handle appeals and complaints. You can check your plan’s star rating on the Medicare Plan Finder tool or by calling 1-800-MEDICARE. You may be in the wrong plan if your plan has a low star rating or if you have experienced problems with your plan’s customer service, such as long wait times, rude or unhelpful representatives, or inaccurate or misleading information.
- You have new or changing health care needs or preferences. Your health care needs and preferences may change over time, and your Medicare Advantage Plan may not be able to accommodate them. For example, you may develop a new health condition that requires a different type of care or medication, or you may want to try a different treatment option or provider that your plan does not cover or support. You may also want to change plans if your personal or financial situation changes, such as moving to a new area, traveling more often, or losing or gaining other health insurance coverage.
If you are in the wrong Medicare Advantage Plan, you have options to switch to a different plan or go back to Original Medicare. However, you cannot switch plans anytime you want. You have to wait for certain enrollment periods, such as the Annual Enrollment Period (Oct. 15-Dec. 7), the Medicare Advantage Open Enrollment Period (Jan. 1-Mar. 31), or a Special Enrollment Period (if you qualify for one). You can learn more about your options and enrollment periods on the Medicare website or by contacting your SHIP.
To help you decide whether you are in the wrong Medicare Advantage Plan, you can use the following table to compare your current plan with other plans or Original Medicare. You can fill in the blanks with the information from your plan’s Evidence of Coverage, Summary of Benefits, or other documents, or from the Medicare Plan Finder tool.
| Feature | Your Current Plan | Other Plan(s) | Original Medicare |
|---|---|---|---|
| Monthly premium | $ | $ | $ |
| Annual deductible | $ | $ | $ |
| Copayment or coinsurance for primary care visit | $ | $ | $ |
| Copayment or coinsurance for specialist visit | $ | $ | $ |
| Copayment or coinsurance for hospital stay | $ | $ | $ |
| Copayment or coinsurance for prescription drugs | $ | $ | $ |
| Out-of-pocket maximum | $ | $ | N/A |
| Network of providers | Any provider that accepts Medicare | ||
| Referral or prior authorization required | Yes/No | Yes/No | No |
| Coverage for out-of-network or out-of-area services | Yes/No | Yes/No | Yes |
| Coverage for extra benefits (such as dental, vision, hearing, fitness, transportation, etc.) | Yes/No | Yes/No | No |
| Star rating (out of 5) | N/A | ||
| Customer service satisfaction | N/A |
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