Doctor holds flask with urine sample and takes a patient’s pulse; Abraham Toorenvliet (1620–1692). The Doctor’s Visit. (Photo by Jacob van Toorenvliet/Buyenlarge/Getty Images)
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It’s been a year since I switched from traditional Medicare to a Medicare Advantage program. How did it work out?
For years my wife and I were covered by traditional Medicare and a secondary insurance plan paid by my wife’s former employer. Last year the insurance rates jumped so much that the amount we’d get was not nearly enough to cover the premiums. We would be paying $600 per month for just my premium. The amount the employer paid was still enough for my wife’s secondary plan.
So after working with an independent Medicare consultant, Janice Scarinzi, we determined that my wife should stay on traditional Medicare with the fully paid secondary insurance but I should either get a supplemental insurance policy (Medigap) for about $300/month or look into joining one of the Medicare Advantage (MA) plans. Janice and I crunched the numbers and decided that one of the MA plans would be the least expensive option with the best coverage available. For the calendar year 2025 that’s been my coverage.
How Did It Work Out?
With a whole bunch of caveats, I have to say it worked out GREAT! For me and for my specific health issues, my specific doctors, and my specific prescriptions.
Each time I saw a doctor, physicians assistant, nurse practitioner, or nurse I had a copay of $45. And for the most part that was all I had to pay. Most lab work and X-rays were fully covered. I still had to pay some for an MRI and a CT. But for this year, now halfway through November, the total I have paid for my health care, including prescription drugs, is $882. Premiums were $0. Had I remained on my wife’s plan I would have spent over $6,000 in premiums and about $500 in copays and prescriptions. Had I enrolled in a Medigap policy I would have paid about $3,500 in premiums and the same $500 in copays and prescriptions, plus another $200 in some uncovered expenses.
In addition, my MA plan also reimburses me up to $1850 for covered dental expenses which, as it turns out, paid for some of my dental work this year. Of course traditional Medicare doesn’t pay any dental expenses so that $1850 is gravy. My MA plan, like many others, also reimburses for vision and hearing aids, which, once again, are not covered by traditional Medicare. I had no vision or hearing expenses this year.
So just looking at the numbers, switching to Medicare Advantage — FOR ME — was definitely the right move.
Here are the caveats.
- The premium I pay for my current Medicare Advantage plan is $0. Not all plans have that same premium, but many do.
- I did not have any major illnesses or injuries and I did not need surgery. I don’t know what the numbers would show if I needed surgery but given that the “Out-of-Pocket Maximum” for my plan is $4700, that’s still less than the premiums and copays I would have paid with traditional Medicare and supplemental/secondary insurance.
- All the doctors I saw this year were in-network. My previous surgeon was not but I didn’t need him this year and I hope I won’t in the future. The “Out-of-Pocket Maximum” for out of network spending is $10,000 and there’s no such equivalent in Traditional Medicare.
- My current copay is $45 which is increasing to $60 in 2026. In 2025 is went to the Doctor about 15 times. Had I needed to go more, for example, if I needed physical therapy and needed to go 3 times a week for two months, that’s $1500 right there. I still might spend less than the Out-of-pocket maximum, but maybe not. And at the level I would be spending just about the same amount as I would with a Medigap policy.
What about Coverage Considerations?
Aye, there’s the rub. Clearly financially my choice to switch to Medicare Advantage was the right decision. But what about the other considerations, such as coverage, approvals and denials, and prescription coverage.
Getting approvals for an MRI under traditional Medicare is a quick and easy process. Not as much so with Medicare Advantage, or so I was told by one of my doctors who ordered an MRI for me. That approval required more of his time and energy, and could take as long as two weeks although generally just a few days more than with Traditional Medicare. Once this year I had to put off a procedure until I got approval from the insurance company. That was annoying but not critical. But what if it was critical? Could the approval have been expedited? I don’t know. In this case it meant only extra days of pain.
Bottom Line
I was lucky this year. But it turns out that even if I wasn’t so lucky and had to spend a lot more time and money seeing doctors and medical professionals, financially I would still be better off with my current decision of getting coverage with Medicare Advantage.
As I said above, that’s for me, my health, my doctors, my year. Next year could be different. But one thing we can be sure of, the costs are going to rise and at some point, going back to Traditional Medicare with a supplemental plan might be the right choice.
What about Next Year?
We’re deep into the selection season when I have to once again decide on my options. I can stay with my current plan, switch to another Medicare Advantage plan, or go back to traditional Medicare with a supplemental plan. After again consulting with the consultant, Janice Scarinzi, crunching the numbers, and reviewing the coverage, staying with the same company but switching plans was the best choice. The big change was in the copay and Out-of-Pocket maximum. Instead of $45, I’ll now be paying $60 per visit for specialists and the maximum will jump to $6750 instead of $4700. But the premium remains at $0 so the choice was obvious. Tune in next year to see whether I made the right choice or would have been better off reverting to traditional Medicare.
