The Truth about Medicare Advantage

Understanding Medicare Advantage: What Every Patient Should Know

Each year, as Medicare enrollment season approaches, many patients ask us which health plan they should choose. It’s an important decision — and one that can have a real impact on your access to doctors, hospitals, and the care you may need in the future. To help patients navigate these choices, The OrthoForum recently hosted a discussion with Dr. Eric Bricker and Dr. Jeffrey Racca. We want to share some of the key takeaways with you.

Medicare’s Open Enrollment Period: What It Means

Medicare’s Open Enrollment Period runs from October 15 through December 7 each year.
This enrollment window allows anyone with Medicare Parts A and/or B to:

• Join, switch, or drop a Medicare Advantage plan.
  
• Return to traditional Medicare.
  
• Change or drop a Medicare Part D (prescription drug) plan. 

It’s important to note that this is different from the Medicare Advantage Open Enrollment Period (Jan. 1 – Mar. 31), which only applies to people already enrolled in a Medicare Advantage plan and allows them to make a single change.

For most patients, the October 15 – December 7 period is the main chance each year to review options, make changes, and ensure your coverage fits your health needs.

What Medicare Advantage Really Is

• Medicare Advantage = your Medicare benefits are run through a private insurance company instead of directly through the government.
  
• Traditional Medicare = the government-run program, which many people pair with supplemental insurance (Medigap) for additional coverage. 

Why Medicare Advantage Looks Attractive

Medicare Advantage plans often advertise lower monthly premiums and added benefits. They may include:

• Lower up-front costs compared to traditional Medicare.
  
• Extra perks like dental, vision, hearing aids, or even grocery gift cards.
  
• The convenience of bundling all coverage into a single plan. 

It’s no surprise these plans are growing rapidly — now covering more than half of all seniors, and projected to reach nearly three-quarters in the years ahead.

The “Catch” Patients Don’t Realize Until It’s Too Late

Despite their appeal, Medicare Advantage plans come with restrictions that may affect your care:

• Restricted Provider Choice: Only certain doctors, hospitals, and surgery centers are covered.
  
• Changing Networks: A provider covered this year may not be covered next year.
  
• Disruption in Care: Some patients must switch doctors or hospitals mid-treatment if their plan changes contracts.
  
• Prior Authorizations: Many services require approval before you can receive them — including MRIs, CT scans, surgeries, and even physical or occupational therapy.
  
• Therapy Limits: Authorizations often cover only 3–8 therapy visits at a time, or sometimes deny care altogether. In contrast, Traditional Medicare generally does not require prior authorization and does not impose severe visit limits for physical or occupational therapy.
  

These barriers often lead to delays, denials, and frustration — both for patients and their physicians.

What Is a Medigap (Supplemental) Plan?

This is where patients often get confused. A Medigap plan is not the same as Medicare Advantage. Instead, it’s additional insurance you can purchase to cover the “gaps” in traditional Medicare (like deductibles, copayments, and coinsurance).

Key points about Medigap coverage:

• Works only with Traditional Medicare (Parts A & B).
  
• Allows you to see almost any doctor or hospital nationwide that accepts Medicare.
  
• No prior authorization requirements for most services.
  
• No severe therapy visit limitations.
  
• Provides predictability in out-of-pocket costs, though premiums are usually higher than Medicare Advantage. 

Think of it this way:

• Medicare Advantage replaces Medicare with a private insurance company’s version of coverage.
  
• Medigap works alongside Traditional Medicare, giving you the freedom and stability of government-run Medicare with added financial protection. 

What Patients Should Ask This Enrollment Period

Before enrolling in a plan, consider asking these important questions:

• Are my doctors, hospitals, and surgery centers covered — not just this year, but long term?
  
• What services require prior authorization?
  
• How many therapy visits are typically approved?
  
• If I need an MRI, CT scan, or surgery, will I face delays waiting for insurance approval?
  
• What are the trade-offs between lower monthly premiums and freedom of choice? 

Why We Care 

Every year, we see patients who face unexpected delays, denials, or limits in their care because of their insurance plan. Many share that they wish they had understood the differences more clearly before choosing. These moments are frustrating — not just for patients, but for families who are already dealing with the stress of a health concern.

Our goal in sharing this information is to help patients avoid those difficult situations. We want you to feel confident in your choices, receive timely care, and focus on recovery and wellness — not on insurance obstacles.

The Bottom Line

Insurance choices can feel overwhelming, but taking the time to ask the right questions now can spare you from regret later. Medicare Advantage plans may look appealing with their lower costs and added perks, but they can come with trade-offs that affect your ability to get the care you need, when you need it.

Remember: Medicare’s Open Enrollment runs October 15–December 7. Take advantage of this window to review your options carefully, talk with trusted advisors, and choose the plan that best supports your long-term health and peace of mind.