Choosing a Medicare Plan? New Study Suggests Looking Beyond the Premium

Every year, roughly 10,000 Americans turn 65 each day and face one of the most consequential financial decisions of later life: choosing a Medicare plan to cover health care costs in older age. 

For many, the choice seems straightforward between the two primary plans for Medicare coverage—Original Medicare (also called “Traditional Medicare”) and Medicare Advantage. Medicare Advantage plans—the privately administered alternative now covering more than half of all Medicare beneficiaries—typically advertise lower premiums, extra benefits like dental and vision coverage, and annual caps on out-of-pocket spending.

But new research led by Xin Hu, PhD, faculty member in the Department of Health Policy and Management at the Rollins School of Public Health and in the Department of Radiation Oncology at the Emory School of Medicine, suggests that those savings can come with limited access to specialty care—which often only becomes visible after a serious diagnosis.

"Many beneficiaries choose Medicare plans based on premiums and extra benefits, without fully knowing what tradeoffs may come later," says Hu. "For an average healthy person, these plans may appear attractive. But given the higher risk of major health events among older adults—including cancer, cardiovascular disease, dementia, and other serious conditions—choosing a plan that preserves access to preferred or high-quality providers can be very important."

What the Study Found

The study, published in JAMA Network Open, is the first population-based look at the oncology networks Medicare Advantage enrollees use, rather than the networks listed in plan directories—which are often inaccurate or outdated. Researchers analyzed care received by more than 807,000 Medicare Advantage beneficiaries diagnosed with eight common cancers between 2016 and 2019, then compared it with the oncologists and cancer care organizations used by Traditional Medicare beneficiaries in the same counties.

Key findings include:

• Medicare Advantage beneficiaries accessed roughly 12% of the oncology organizations, 7% of the medical or surgical oncologists, and 12% of the radiation oncologists that Traditional Medicare beneficiaries used in the same counties.
• Approximately 90% of Medicare Advantage plans had narrow effective oncology networks. It is possible that a plan might technically contract with lots of oncologists, but they may not take new patients, aren't nearby, or aren't reachable in practice.
• Fewer than one in four people on Medicare Advantage plans (23.4%) had recorded visits to a National Cancer Institute-designated comprehensive cancer center, which offer multidisciplinary care, access to clinical trials, and cancer sub-specialists—all of which have been shown to improve cancer survival.
• Networks were narrowest in Health Maintenance Organization (HMO) plans, meaning they had the smallest pool of cancer doctors available to them compared to people in other plan types. Plans in non-metropolitan counties were less likely to include an NCI-designated center.
• Among the 154 Georgia counties in the analysis, roughly three-quarters (115) had no beneficiaries on Medicare Advantage plans with recorded visits to an NCI-designated cancer center.

“On paper, these plans cover cancer care. In practice, a Medicare Advantage enrollee can reach only a small fraction of the oncologists and cancer centers their Traditional Medicare neighbors use in the very same county,” says Hu. “A cancer diagnosis is overwhelming on its own. Then finding out that the specialists or cancer center you need are out of network is a barrier at the worst possible moment, and it traces back to a plan decision made long before anyone saw cancer coming. From a policy perspective, we need better disclosure of network breadth, and a reconsideration of network adequacy standards.”

Complications of Switching Plans

A common assumption is that an enrollee who experiences provider access issues under Medicare Advantage can simply switch back to Traditional Medicare, which allows beneficiaries to see any clinician who accepts Medicare.

Traditional Medicare has no annual cap on out-of-pocket costs, which is why some enrollees pair it with supplemental insurance, known as Medigap, to help cover cost-sharing requirements. But outside of a beneficiary's initial enrollment window, Medigap insurers in most states can use medical underwriting to deny coverage or charge higher rates based on health status. 

"We encourage beneficiaries currently enrolled in Medicare Advantage plans to review their provider networks and plan benefits as early as possible to make an informed plan change if needed," says Hu. "Once someone is diagnosed with a major health condition such as cancer, switching back to Traditional Medicare may not fully solve the access or affordability issue if they cannot obtain Medigap coverage."

Several major cancer centers, including MD Anderson and Mayo Clinic, have recently ended contracts with certain Medicare Advantage plans, suggesting provider networks may grow even narrower.

The Bottom Line 

For people weighing their Medicare plan options, Hu advises understanding provider networks which can matter if a serious illness like cancer arrives later. "Patients treated at NCI-designated cancer centers have been associated with better outcomes," says Hu. "It’s important for beneficiaries to factor provider access into their decision-making when selecting Medicare plans, rather than focusing only on premiums and supplemental benefits.”

For more assistance on choosing a Medicare plan, contact your local State Health Insurance Assistance Program (SHIP) for personalized guidance with a counselor.