Ask the Expert: Medicare Advantage versus supplemental plan

For years, my husband and I were satisfied with our Medicare Advantage plans. Then he needed rehab facility care after a hospital stay. The insurer wouldn’t agree to the facility the doctor recommended. My husband went to one where care wasn’t good. In days, he was hospitalized again, and then off to a second rehab facility. There, I was told that if I had a Medicare supplement plan, we’d have been able to go to the facility the doctor had wanted. Is it true the doctor is in control if you have a Medicare supplement plan, and the insurance company is in control if you have an Advantage plan?   

Medicare Advantage plans are sold by insurance companies, and they cover health care services from the insurer’s provider network. Advantage plans typically have no coverage or much more limited coverage for out-of-network medical services.

The alternative is traditional Medicare, which you buy directly from the government. Traditional Medicare covers the services of all doctors and medical facilities that accept Medicare. (But unlike many Advantage plans, it doesn’t include prescription drug coverage, which you must buy separately.) The downside: Traditional Medicare costs more than Advantage plans. One reason: It only pays 80% of the “reasonable and customary” fees for insured medical expenses. You pay 20%. If a doctor charges $75 for a service for which Medicare thinks the “reasonable and customary” fee is $60, it pays the doctor $48 (80% of $60). Your share: the $27 balance.

That’s why you need a Medicare supplement or Medigap policy. It pays for gaps in traditional Medicare coverage. But Medigap policies only supplement traditional Medicare. You can’t buy a Medigap policy for what Advantage plans don’t cover.

The bottom line

With Medicare Advantage, your choice of medical providers is limited to an insurance company’s network.

More information

bit.ly/mediGAP

bit.ly/AdvantageMarketing