What is the biggest coverage gap most people don't know about with a Medicare Advantage plan?
Answered by 8 licensed agents
There are many: in/out of network costs, inpatient admissions costs, chemotherapy, skilled nursing costs and network restrictions, possible travel/network restrictions, just to name a few. Each plan has a lengthy summary of benefits which is required to list required co-pays/cost of care within the parameters of the plan.
Most people don't realize that a standard Medicare Advantage plan carries a 20% co-pay on chemotherapy — and if you ever get that diagnosis, you will hit your maximum out of pocket, it's not a matter of if, it's when. That's why I always say having a Medicare Advantage plan without Umbrella coverage is like driving without a seatbelt — everything is fine until it isn't. Umbrella coverage fills that gap so that if the worst happens, you're protected financially and can focus on getting better instead of worrying about how you're going to pay for it.
The biggest coverage gap is Network restrictions. Most Plans do not have large provider networks and HMO's do not allow out of network services unless emergency situation. Many people think PPO plans are the answer and sometimes they are. However more and more PPO plans have poor out of network coverage. for example a plan may allow you to go out of network to see a doctor and instead of a copay you have a coinsurance. This has become more and more common and the coinsurance has gotten higher and higher over the years.
One of the biggest coverage gaps with a Medicare Advantage plan is that many people don’t realize they can face high out-of-pocket costs for hospital stays, chemotherapy, skilled nursing, or out-of-network care — even though the plan may have low or $0 premiums.
The biggest coverage gap most people miss with Medicare Advantage (MA) is restricted access to specialized care and out-of-network providers. Because most MA plans are HMOs or regional PPOs, you are generally locked into localized networks. If you need a certain specialist or travel frequently, you could face denied coverage or huge staggering out-of-pocket costs.
Hospital stays and skilled nursing coverage could push the max out of pocket the quickest. When hospital is averaging almost 375 a day for 7 days and 214 a day for skilled nursing(after the first 20 days if they are covered) . this makes for big chunks very fast.
The biggest coverage gap in Medicare Advantage plans is the costs for a hospital stay. Though there is a maximum out of pocket on what one will pay in a year, many Medicare beneficiaries are not prepared for the per day costs they would incur if they were hospitalized or the post-release care if they need additional institutional care. Having a hospital indemnity plan can help cover costs for the hospital stay; long term care coverage or tapping into the living benefits of a life insurance policy (if the policy has them) can help with post-release institutional care.
With every Medicare Advantage program their is a maximum out of pocket, those costs need to be met for hospitalization and extenuating circumstance costs that can be brought on by a sudden illness or accident. Although the Medicare Advantage plan in most cases doesn't have a premium their are additional co-pays for specialists, emergency room visits and other services that require additional payments, make sure you go over these thoroughly with your agent or broker before applying for these plans.
