Written by Jennifer Kleinhans
Article
Do Medicare Replacement Plans pay my providers the same amount that Traditional Medicare would?
Absolutely not. Medicare Replacement Plans are not obligated to pay under the Medicare reimbursement rules or even to utilize the Medicare fee schedule. Their tactics often include routinely undercutting reimbursement, especially for smaller providers. In fact, some insurance companies offer capped rates which are well below our operating costs….often less than you would pay for an hour massage, hair appointment or dog groomer visit.
Unfortunately, HARTZ PT is unable to accept United Healthcare Plans as an in-network provider due to their time intensive authorization requirements as well as reimbursement well below our costs.
Here are some facts:
✅ Original Medicare
- Administered by: Federal government.
- Coverage:
Part A: Hospital insurance (inpatient care, skilled nursing, hospice, some home health).
Part B: Medical insurance (doctor visits, outpatient care, preventive services, medical supplies). - Extras: Does not include routine dental, vision, hearing, or prescription drugs (you need separate Part D and/or Medigap for those).
- Provider Access: Any doctor or hospital that accepts Medicare nationwide—no network restrictions.
- Costs:
– Part B premium (about $185/month in 2025).
– Deductibles: Part A ($1,676 per benefit period), Part B ($257/year). – As of 2025, subject to change in 2026.
– Coinsurance: Typically 20% for Part B services. - Out-of-Pocket Limit: No annual cap (unless you buy Medigap). [medicare.gov], [ncoa.org], [healthline.com]
✅ Medicare Advantage (Part C)
- Administered by: Private insurance companies approved by Medicare.
- Coverage:
– Includes Part A and Part B services.
– Most plans also include prescription drugs (Part D).
– Often adds extras like dental, vision, hearing, fitness programs. - Provider Access: Usually limited to a network (HMO or PPO). Care outside the network may cost more or not be covered (except emergencies).
- Costs:
– Still pay Part B premium.
– May have an additional plan premium (sometimes $0).
– Copays and coinsurance vary by plan. - Out-of-Pocket Limit: Annual cap on covered services (provides financial protection). [medicare.gov], [forbes.com], [humana.com]
Pros and Cons of Medicare Advantage Plans:
✅ Pros
- All-in-One Coverage
– Combines Part A (hospital), Part B (medical), and usually Part D (prescription drugs) in one plan. - Extra Benefits
– Often includes dental, vision, hearing, fitness programs, and sometimes transportation or meal services. - Predictable Costs
– Annual out-of-pocket maximum for covered services (Original Medicare doesn’t have this). - Lower Premiums
– Many plans have $0 additional premium beyond the Part B premium. - Care Coordination
– Managed care approach can help streamline services and improve preventive care.
❌ Cons
- Network Restrictions
– Limited to doctors and hospitals in the plan’s network (HMO/PPO). Out-of-network care can be costly or not covered. - Prior Authorizations
– Many services require approval before you receive care, which can delay treatment. - Plan Variability
– Benefits, costs, and provider networks differ widely by plan and location. - Travel Limitations
– Coverage outside your service area (especially out-of-state) may be limited. - Potential Higher Costs for Complex Care
– Copays and coinsurance can add up if you need frequent or specialized care.
Tips for choosing the right Medicare plan:
✅ 1. Check Your Providers
- If you have preferred doctors or hospitals, make sure they’re in-network for Medicare Advantage plans.
- Original Medicare allows you to see any provider that accepts Medicare nationwide.
✅ 2. Review Prescription Drug Needs
- List your medications and compare costs under each plan.
- Some Medicare Advantage plans include Part D; with Original Medicare, you’ll need a separate Part D plan.
✅ 3. Consider Extra Benefits
Do you need dental, vision, hearing, or fitness perks?
- Medicare Advantage often includes these.
- Original Medicare does not (unless you buy supplemental coverage).
✅ 4. Evaluate Travel & Flexibility
- If you travel frequently or live in multiple states, Original Medicare offers more flexibility.
- Medicare Advantage plans may limit coverage outside your service area.
✅ 5. Compare Costs Beyond Premiums
- Look at deductibles, copays, coinsurance, and out-of-pocket maximums.
- Medicare Advantage has an annual cap; Original Medicare does not (unless you add Medigap).
✅ 6. Check Star Ratings
- Medicare rates Advantage plans (1–5 stars) based on quality and customer satisfaction.
- Higher ratings often mean better service.
✅ 7. Use Official Tools
- Visit Medicare.gov Plan Finder to compare plans by cost, coverage, and ratings.
If you have questions you may email Jen at jkleinhans@hartzpt.com.