By Jeannine Lindstom

I often hear from clients or their family members that an assisted living or skilled nursing facility has encouraged them to leave their Medicare Advantage plan and return to Original Medicare. The suggestion is usually made with the idea that it will provide broader access to care and fewer requirements for service approvals. While this advice may be well-intentioned, there are important financial considerations to understand before making a change.

Facilities often view Original Medicare as simpler to work with because claims are typically processed with fewer prior-authorization requirements than Medicare Advantage plans. However, these authorization measures exist to ensure services are medically necessary and to help prevent fraud, waste, and abuse. Unfortunately, when facilities encourage residents to make the switch, the financial implications for the individual are not always fully explained.

How Original Medicare Works

Original Medicare consists of two main parts:

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing facilities, hospice, and some home health care. Most people do not pay a premium for Part A if they paid Medicare taxes while working.
• Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, and durable medical equipment. Beneficiaries pay a monthly premium for Part B, along with an annual deductible and generally 20% coinsurance for most services.

It is important to note that Original Medicare does not include prescription drug coverage (Part D) or place a cap on out-of-pocket expenses.

The Role of Medicare Advantage Plans

Medicare Advantage (Part C) plans, offered by private insurance companies, combine Part A and Part B coverage as well as additional benefits not covered under Original Medicare. Many Medicare Advantage plans have a low premium for beneficiaries.

Medicare Supplement (Medigap) Plans

When first enrolling in Medicare, beneficiaries can choose to add a Medicare Supplement (Medigap) plan to Original Medicare. Medigap helps pay the “gaps” left by Original Medicare, such as coinsurance and deductibles. Those who choose a Medicare Supplement typically pay a monthly premium but often have little to no out-of-pocket costs for Medicare-approved services after meeting the Part B deductible.

The Cost Factor Facilities Rarely Mention

When facilities encourage residents to move from Medicare Advantage to Original Medicare, what often goes unmentioned is that people who make this switch do not automatically qualify for a Medicare Supplement (Medigap) plan to help pay the 20% of costs that Medicare does not cover.

Outside of very specific circumstances—such as your initial enrollment period or certain guaranteed issue rights—Medigap coverage typically requires medical underwriting. This means the insurance company can review your health history and may deny coverage or charge higher premiums based on preexisting conditions.

For older adults or those with significant health needs, this can leave them without supplemental coverage—and fully responsible for 20% of all Medicare-approved costs with no cap on expenses.

Key Takeaways

Before making any changes to your Medicare coverage:

• Review your current Medicare Advantage plan benefits.
• Understand potential costs under Original Medicare if you cannot qualify for a Medigap plan.
• Consult with a licensed Medicare advisor or your state’s Health Insurance Assistance Program (SHIP) for unbiased guidance.

Medicare decisions can have lasting financial and health implications. Taking the time to fully understand your options can help prevent unexpected coverage gaps or out-of-pocket costs in the future.

Jeannine Lindstom is the co-owner of Medicare Solutions, a Kansas City-based firm that helps seniors choose Medicare plans. For more information, visit the Medicare Solutions website or call 816-309-5615.

Government Disclaimers: This is a solicitation of insurance. Not connected with or endorsed by the U.S. government or the federal Medicare program.