Medicare is a complicated system that mixes public and private insurance providers. As reported by the Scripps News Service on Oct. 21, 2022 (“Why Is Medicare So Complicated?”):

“By the government’s last count in 2021, 64 million adults were enrolled in Medicare. But that doesn’t mean it’s simple to navigate. The Medicare maze is growing more entangled over the years, as Congress adds new benefits, exceptions, and penalties.”

As KFF explains in its Sept. 18, 2023 issue brief, What to Know about the Medicare Open Enrollment Period and Medicare Coverage Options:

“People with Medicare may choose to receive their Medicare benefits through traditional Medicare or through a Medicare Advantage plan, such as an HMO or PPO, administered by a private health insurer. People who choose traditional Medicare may sign up for a separate Medicare Part D prescription drug plan for coverage of outpatient prescription drugs and may also consider purchasing a supplemental insurance policy to help with out-of-pockets costs if they do not have additional coverage from a former employer, union, or Medicaid. People who opt for Medicare Advantage can choose among dozens of Medicare Advantage plans, which include all services covered under Medicare Parts A and B, and often include Part D prescription drug coverage as well.”

Further regarding Medicare and Medicare Advantage plans:

“Traditional Medicare and Medicare Advantage both provide coverage of all services included in Medicare Part A and Part B, but certain features, such as out-of-pocket costs, provider networks, and access to extra benefits vary between these two types of Medicare coverage. When deciding between traditional Medicare and Medicare Advantage, people may want to consider a variety of factors, such as their own health and prescription drug needs, financial circumstances, preferences for how they get their medical care, and which providers they see. These decisions may involve careful consideration of premiums, deductibles, cost sharing and out-of-pocket spending; extra benefits offered by Medicare Advantage plans; how the choice of covedicare advantage marketingrage option may affect access to certain physicians, specialists, hospitals and pharmacies; rules related to prior authorization and referral requirements; and variations in coverage and costs for prescription drugs.

“People may prefer traditional Medicare if they want the broadest possible access to doctors, hospitals and other health care providers. Traditional Medicare beneficiaries may see any provider that accepts Medicare and is accepting new patients. People with traditional Medicare are not required to obtain a referral for specialists or mental health providers. Additionally, prior authorization is rarely required in traditional Medicare and only applies to a limited set of services. With traditional Medicare, people have the ability to choose among stand-alone prescription drug plans offered in their area, which tend to vary widely in terms of which drugs are covered and at what cost.

“People may prefer Medicare Advantage if they want extra benefits, such as coverage of some dental and vision services, and reduced cost sharing offered by these plans, often for no additional premium (other than the Part B premium). Additionally, Medicare Advantage plans are required to include a cap on out-of-pocket spending, providing some protection from catastrophic medical expenses. Medicare Advantage plans also offer the benefit of one-stop shopping (i.e., people who enroll have coverage under one plan and do not need to sign up for a separate Part D prescription drug plan or a Medigap policy to supplement traditional Medicare).”

Concerns over sales and marketing tactics used by some Medicare Advantage plan providers led the Centers for Medicare and Medicaid Services to issue new rules which went into effect in 2023. In its report Sept. 15, 2023 report entitled How Health Insurers and Brokers Are Marketing Medicare, KFF noted:

“In May 2022, the National Association of Insurance Commissioners (NAIC) sent a letter to Congress urging action on this issue, citing concerns about misleading claims and aggressive sales tactics. The following November, the majority staff of the Senate Finance Committee released a report detailing complaints and associated marketing materials from key stakeholders across 14 states. In response, CMS released new regulations, effective June 2022 and June 2023, tightening restrictions on health insurers and third parties who market Medicare Advantage and Part D plans.”

CMS Medicare Marketing Guidelines

Information about Medicare plans, including plan comparisons, is available from the federal Centers for Medicare and Medicaid Services at 1-800-MEDICARE or by going to Medicare.gov.

World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems and policies in the US and sixteen other nations.

Page last updated October 15, 2023 by Doug McVay, Editor.