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  • Writer's pictureValerie Smith, APRN

Why We Do Not Recommend the Medicare Advantage Plan



If you ask our healthcare team at Paducah Rheumatology our opinion on the Medicare Advantage Plans, our answer may surprise you. It is not a health insurance plan we recommend and this article covers all of the reasons why. These main reasons include the small provider networks, the financial structures of the plans and prior authorization typically needed for services.


Small Provider Networks


A question you should always ask before signing up for new health insurance is, “Will this plan cover all of my healthcare providers?” Oftentimes, the Medicare Advantage Plan has a small network of providers and the odds that your healthcare providers will all be in network for the plan may be low. This means it may be hard for your doctor to refer you to specialists as needed because they may not be within the provider network of this plan.


Therefore, this plan is not recommended by Paducah Rheumatology because it may restrict the healthcare providers you are eligible to see.


Financial Structure of the Plan


Our healthcare providers at Paducah Rheumatology do not recommend the Medicare Advantage Plan because it may put our patients in financial risk. The billing and reimbursement processes of these plans are complicated because they often subject patients to high copays or coinsurance amounts. Many of the cutting edge treatments for arthritis are unfortunately expensive, and these cost-sharing amounts often keep patients from accessing these treatments. While you may be accustomed to using a drug company’s copay assistance program to defray out of pocket costs on a commercial insurance plan, these are prohibited by Medicare so there is no pathway to defray your out of pocket costs.


Prior Authorization Needed for Services


Our healthcare providers at Paducah Rheumatology do not recommend the Medicare Advantage Plan because of the prior authorization typically required for treatments and procedures. We as healthcare providers want to provide you with the best treatment possible as quickly as possible so you can be on your way to living your best life.


Unfortunately, the Medicare Advantage Plan will often require approval from the insurance company before our healthcare providers can perform specific tests, procedures or treatments. This process can be tedious and time-consuming which is not ideal for our healthcare providers or our patients. While we are accustomed to encountering such barriers to care from commercial insurance providers, we are much more readily able to schedule tests and treatments for patients on traditional Medicare than those on Advantage plans.

Because of how prior authorization of healthcare treatments and services can delay our patients’ healthcare needs, we do not recommend the Medicare Advantage Plan.


Additional downsides to the Medicare Advantage Plan include:

  • Plans do not travel with you and will not cover medical costs if needed while you are on a trip or away from home. This means if you need medical treatment away from home, you may only be eligible for emergency treatment depending on your plan

  • The low pay to healthcare providers may reduce the quality of the healthcare providers who will accept this plan, potentially jeopardizing your medical treatment

  • Low premiums but high out of pocket costs can cause financial complications for patients. Typically, these plans have high-deductibles which may prevent you from receiving medical treatment or services depending on your financial situation

  • This plan may change its benefits annually which makes your plan eligible for a change in financial structure, treatments it will cover and the providers who are within network for your plan. Therefore, it is subject to change quickly and may not always be in your best interest.


With the fall medicare enrollment period approaching this October, we want to make our patients aware of the downsides of the Medicare Advantage Plan so you can best make an informed decision about the health insurance you choose for yourself and your family.


We encourage you to speak to your insurance about different health insurance plans available to you as each plan is diverse and suited to each patient depending on your specific healthcare needs. If you are on, or considering, a biologic therapy for your arthritis, feel free to contact us as well, as we are well verses in how these treatments are covered by these plans. And most importantly, if you are on a biologic treatment on a traditional Medicare plan, please do not switch to an Advantage plan without reaching out to us to understand the implications on your access to treatment.


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