<![CDATA[]]> https://dennis-k.websitex5.me/blog/ EN Mon, 09 Feb 2026 19:18:00 +0100 Incomedia WebSite X5 Pro <![CDATA[Level Funding Helps Manage Costs]]> imblog
Level funded plans continue to gain traction in the health care marketplace. In fact, 42% of small firms in 2024 reported having a level funded plan, compared to just 7% in 2019, according to the Kaiser Family Foundation Employer Health Benefits Survey.2
What’s driving the increased adoption of these plans? As health care costs continue to rise and broader economic uncertainty persists, plan sponsors are seeking more cost-effective plan designs. Enter level funding.
Level funded plans may reduce costs by passing savings to the plan sponsor—unlike fully insured plans, where any savings remain with the insurer. With level funding, plan sponsors may earn a potential surplus refund for their health plan that can be applied to the following year’s plan.1 As a result, they may pay an average of 22% less with UnitedHealthcare Level Funded plans compared to fully insured plans.
Plan sponsors may pay
22% less on average under a UnitedHealthcare Level Funded plan compared to a fully insured plan3
Understanding level funding
“Our level funded plans give businesses more affordable options without sacrificing the ability to tailor benefits to meet employees’ needs.”
— John Terry, Vice President of Small Business Sales Account Management, UnitedHealthcare Employer & Individual Local Markets
Understanding level funded plans
While there’s been increased adoption of level funded plans, experts find that there’s confusion about how they work.2 This is understandable, given the complexity around how they’re funded and their regulatory requirements. However, at their core, level funded plans are generally self-funded plans with 3 key differences (though certain plan components may vary based on the carrier):
  • Stop loss insurance to help mitigate claims risk
  • An opportunity for a surplus refund1
  • A third-party claims administration agreement
Level funded plans can also include monthly reports with data that plan sponsors can use to track health care usage, as well as wellness programs that may increase plan participant engagement and reduce costs.

“Level funded allows us to be more agile and able to react quicker to changes and the needs of the market. As a type of self-funded health plan, level funded plans are built to provide the pricing stability employers want and need, and provide them an opportunity for a surplus refund.”
— John Koewler, Regional Vice President of Small Business, UnitedHealthcare Employer & Individual West Region
“Level funded plans mitigate risk associated with the self-funded model. There is no risk of additional liability outside of what is being funded.”
— John Koewler

To take a closer look at how level funded health plans help manage costs for plan sponsors, here’s how they compare to self-funded and fully insured plans:
1.Level funded plans offer predictability and mitigate the risks of self-funded plans
Similar to a self-funded plan, level funding allows plan sponsors to assume the financial risk of providing health services to their workforce by directly paying for plan participant medical claims.
How do these plans mitigate risk? Plan sponsors with level funded plans pay a fixed monthly fee, which covers the maximum claims liability, administrative fees and stop loss insurance to protect against unexpectedly high claims costs and utilization.
In a self-funded model, the plan sponsor pays more if claims costs are higher than anticipated and gets money back if claims costs are lower at the end of the plan year. Level funded plans, however, cover the cost of individual or aggregate claims that exceed the plan’s maximum, while offering the plan sponsor an opportunity to receive money back if lower-than-expected claims produce a surplus.
2. The plan may receive a surplus refund with level funded plans
With a fully insured plan, the insurer assumes the financial risk for providing health services to the plan sponsor group. For a fixed cost paid by the plan sponsor, the insurer pays covered health care claims costs and covers administrative costs, sales commissions and taxes. At the end of the plan year, if the actual medical and pharmacy claims costs are higher than expected, the insurer pays them. The insurer keeps the difference if they’re lower.
In contrast, a plan sponsor with a level funded plan is insured against higher-than-expected claims costs, with the plan potentially receiving a surplus refund resulting from lower-than-expected claims costs.
In other words, plan sponsors have an extra incentive to keep their workforces healthy to increase their potential surplus refunds. UnitedHealthcare Level Funded plans, which include wellness programs and virtual care, can help achieve this goal.
3. Level funded plans offer greater insights to help manage costs
Plan sponsors with level funding can receive detailed monthly data reports to help them better understand participant utilization of health services and manage their benefits, which isn’t the case with most fully insured plans.
“With our monthly reporting package, plan sponsors are able to see how their group is running and can see trends and utilization within their specific population. The report contains a lot of impactful and useful information,” Koewler says. “They don’t have to wait until the renewal period at the end of the year before they can understand how participant behavior may be driving up costs.”
These insights may enable plan sponsors to alert individual participants that:
  • Low-cost generic medications can often be substituted for brand name medications
  • Going to urgent care may be more appropriate and less costly than going to the emergency room
  • Seeing their primary care provider virtually rather than in person can save them time and money
“Detailed data reports are a huge advantage, especially for small businesses, by giving them insights into their virtual care usage, ER use, pharmacy utilization and network strategy,” Koewler says. “Tracking these things over time and making informed decisions as needed can help drive a better member experience.”
And now the Surest® health plan is available for level funded small businesses — bringing cost transparency to a new subset of consumers. With Surest, plan participants are empowered to make decisions that may affect plan sponsor costs, since the plan features an easy-to-use app, with clear upfront copays — not estimates.
4. Plan participant experience is key within the level funded model
UnitedHealthcare Level Funded plans include wellness programs and 24/7 virtual care options, which may help employees and their families play a more active role in their health care and save on out-of-pocket costs.
Plan participants in some markets may be invited to join UnitedHealthcare Rewards, where they can earn up to $1,000 for completing healthy activities. To offer participants more convenience, 24/7 virtual care is available for a variety of conditions, including general medical care and behavioral health counseling.
“The plan participant experience including virtual, health engagement and plan design options is what distinguishes our level funded plan,” Koewler says. “It helps to increase plan sponsor satisfaction and engagement for plan participants; for plan sponsors, it’s the opportunity for lower costs and the chance to achieve a surplus refund."
]]> Mon, 09 Feb 2026 18:18:00 GMT https://dennis-k.websitex5.me/blog/?level-funding-helps-manage-costs https://dennis-k.websitex5.me/blog/rss/000000014 <![CDATA[Taxpayers pay most of ObamaCare premiums]]> imblog
Mark Howell
Mark Howell is a Research Assistant at Paragon Health Institute. He is passionate about advancing free-market solutions to improve healthcare access and affordability

In 2014, taxpayers covered 68 percent of costs. From 2014 to 2020, the total premium increased from about $4,500 to $8,000. The enrollee amount stayed almost flat during this period as taxpayers picked up almost the entire cost of the premium increase.

By 2020, taxpayers covered 80 percent—a significant increase from Obamacare’s first year.
From 2021 to 2025, Biden’s COVID credits (in light blue) replaced much of the enrollee share with new subsidies. That increased the government’s share of the premium to 93 percent of the cost. By comparison, KFF found that in 2024, enrollees in employer-sponsored plans paid on average 25 percent of their premium. (Economic theory shows that employees pay all of the premiums in the form of foregone wages.)

After this year, the COVID credits expire. But the underlying Obamacare subsidy will still cover more than 80 percent of the typical enrollee’s premium—a massive subsidy.
]]> Sun, 08 Feb 2026 13:29:00 GMT https://dennis-k.websitex5.me/blog/?taxpayers-pay-most-of-obamacare-premiums https://dennis-k.websitex5.me/blog/rss/000000013 <![CDATA[Obama Skyrocketing Premiums ]]> imblog
A fully implemented Affordable Care Act would “bend the cost curve” in health care, “moving the health care system toward higher quality and more efficient care,” according to a White House statement in 2013.

Many people now agree that didn’t happen.

“We pay more than any other country in the world for worse health care,” Sen. Elissa Slotkin (D-Mich.) said while campaigning for office in 2024.

“Families pay more, get less, and we’re left with few choices,” Rep. Mike Lawler (R-N.Y.) testified in a December 2025 committee hearing.

A combined 70 percent of Americans believe the U.S. health care system is either in crisis or has major problems, according to a 2025 Gallup poll.

Health insurance premiums have more than doubled since the major provisions of the Affordable Care Act, commonly known as Obamacare, began in 2014, rising twice as fast as inflation. And satisfaction with the cost of health care registered a record low in 2025, at 16 percent.

How did that happen?

Consumers have said that insurance companies are responsible. Insurers shift the blame to hospitals and pharmaceutical companies. Pharmaceutical companies say pharmacy benefit managers are at fault. Political parties blame each other.
Some independent observers agree that the rise in premiums, especially recently, is largely driven by external forces, including the increased use of expensive medications, rising labor costs, and inflation, which reached a 40-year high in 2022.
Others see a more basic cause, one with roots in the Affordable Care Act. Some of the same policies that make Obamacare popular with consumers are actually cracks in its foundation, these observers say. Those policies all but guaranteed premium increases, especially in the program’s early years.
Here are the key provisions of Obamacare, which some experts say undermined its success

Foundations of Obamacare

The Affordable Care Act made profound changes in the health insurance industry. One of the changes required insurance companies to issue health insurance in the individual and small-group markets to any applicant, regardless of preexisting illness.

Americans generally like that idea. More than two-thirds of people say that provision is very important, according to polling by health care research group KFF. That includes 54 percent of Republicans, 66 percent of independents, and 79 percent of Democrats.
Known as guaranteed issue, this was one of four foundational provisions built into Obamacare to make health insurance available to more Americans.
The second foundation was community rating, which required insurers to rate, or price, their plans based on the demographic profile of a community, with only limited increases based on age and tobacco use. According to this provision, premiums for people of the same age group in the same geographic area are pretty much the same.
The third foundation was the requirement that certain essential health benefits be included in every plan, except for catastrophic health plans. This ensured that consumers would get real value for their money and not be surprised to find that services such as emergency room visits and maternity care were not covered.
The Department of Health and Human Services eventually decided on 10 essential health benefits.
The final foundation was the individual mandate. This required most adults to either buy health insurance or pay a fine. The point was to keep overall costs down by ensuring that young, healthy people, who would likely incur fewer charges, would stay in the market. The fine was $95 per adult in 2014 and rose to $695 by 2016

Although some of these provisions were popular with consumers, they increased both cost and risk for health insurers. And although the new rules made insurance premiums lower for some customers, prices went up for some others.
And the new rules applied to all new plans for individual and small-group insurance sold in the United States, guaranteeing a shift in the entire market, not just the Obamacare exchanges


Higher Cost, Increased Risk

As the Affordable Care Act was being considered and implemented, stakeholders warned that these sweeping changes could make insurance more expensive. At a minimum, they said, the requirement that plans cover a suite of essential health benefits could raise premiums.

The Board of Health Care Services at the National Acadamies warned that including too many essential health benefits could make insurance unaffordable for individuals and small businesses.

“If this occurs, the principal reason for the [Affordable Care Act]—enabling people to purchase health insurance and thus covering more of the population —will not be met,” the board wrote in 2012.
Insurers were also wary. America’s Health Insurance Plans, an industry trade group, told regulators in a 2012 letter that the choice of essential health benefits would have “far-reaching implications” on the affordability of health insurance



Increased risk was also a concern.
Insurers speculated on the legality of the individual mandate and warned that Obamacare wouldn’t be viable without it.

“The insurance market reforms cannot function as Congress intended without the mandate and therefore should be struck down if the mandate is held to be unconstitutional,” the insurance trade group argued in a brief filed with the Blue Cross Blue Shield Association.
The old risk management strategy of medical underwriting—pricing premiums based on the underlying health risks of an individual or members of a small group—was no longer an option.

Community pricing would reduce premiums for people with preexisting conditions or other health risks. But premiums would increase for younger and healthier people. Some observers feared that younger people might stay out of the market, then buy health insurance only when they became ill.
If that happened, it would throw off the risk predictions insurers had made, leaving them with an older, sicker population to cover. In the insurance business, this situation is known as adverse selection.

Timothy Jost of Washington and Lee University School of Law, in a 2010 report for The Commonwealth Fund, called that possibility “the greatest threat facing exchanges.”

Michael F. Cannon, a health policy expert at the Cato Institute, in 2010 saw the potential for an “adverse-selection death spiral.”

Risk Mitigation

The Affordable Care Act acknowledged the increased risk for insurers and included three provisions to keep premium prices stable.

First, the law included a risk adjustment. This was meant to protect health plans that wound up ensuring an exceptionally high-risk group of people. Plans that wound up with a lower-than-average risk group would make a payment to plans having a higher-than-average risk group.

Second, the law included a reinsurance program. This was to help plans deal with unexpectedly high medical costs for an individual enrollee. All insurers paid into a reinsurance pool. At the end of the year, each could submit a claim for individual enrollee costs that exceeded a certain threshold. This program, which was intended to be temporary, ran from 2014 through 2016.

Third, the law created risk corridors. This was to help health plans that had total claim payments exceeding the predicted amount. Plans that had lower-than-expected claim totals would pay into a fund. The fund would make payments to plans with claim costs higher than their target amount. This program was also intended to be temporary and ran from 2014 through 2016.


The Spiral Begins
The first several years of Obamacare had lower-than-expected enrollment, higher-than-anticipated costs, and diminishing choice in the marketplace.

Enrollment was significantly lower than expected in the early years, which observers had warned could be a sign of adverse selection.

After a shaky start due to glitches in the online marketplaces, enrollment in 2014 actually exceeded the modest Congressional Budget Office forecast.
Yet the overall market grew by just 4.2 million that year, as many of the 8 million Obamacare enrollees were people who had moved over from the commercial market, according to a report by Amanda E. Kowalski of Yale University.

By 2018, Obamacare enrollment stood at 11.8 million, nearly 1 million less than in 2016 and less than half of the 25 million predicted by that date.

Data suggest that many of the missing enrollees were young adults.

Obamacare needed an enrollment mix that included 38 percent young adults to avoid a “death spiral,” the Cato Institute reported in early 2014.

At the close of its first enrollment period in 2014, Obamacare had an enrollment pool that was just 28 percent young adults aged 18–34. A Commonwealth Fund report indicated that people whose premiums increased had been slightly less likely to buy insurance in 2014. Young adults would have been among those whose rates went up.

The individual mandate, which aimed to offset this factor, faced court challenges beginning in 2010. Although it was not ultimately ruled unconstitutional, Congress set the penalty for noncompliance at $0 in 2017, effectively ending the federal mandate.

Enrollee age was not the only indicator of adverse enrollment, Kowalski reported. Her analysis of cost data concluded that marketplaces in at least 16 states experienced adverse enrollment in 2014.

Data indicate that the cost of insuring Obamacare enrollees exceeded expected levels in the early years.
The reinsurance program had obligations exceeding income by nearly $10 billion over three years.

The risk corridors program fared no better. Income was insufficient to meet obligations in 2014, so all 2015 income and at least a part of 2016 income was used to pay off the 2014 shortfall.

The increased coverage requirements had the predictable effect of increasing premium prices, according to a 2017 report by the Department of Health and Human Services.

“In most states these regulations increased insurance coverage requirements and would be expected, on average, to increase the price of [Affordable Care Act]-compliant plans relative to pre-[Affordable Care Act] plans all else equal,” the report reads.

Premiums increased by 22 percent in the first year and a total of 84 percent by 2018.

Insurers began to leave the marketplace. In 2015, an average of 8.8 insurers in each state participated in Obamacare, according to KFF. By 2018, that number had dropped to less than six.

The COVID Years and Beyond

In the middle years of Obamacare, enrollment decreased, then plateaued after reaching a high of 12.7 million in 2016. Premiums decreased somewhat, too, dropping by about 9 percent over four years from their high point in 2018. And insurer participation ticked up slightly in 2019.

Then came COVID-19 and the enhanced premium subsidies created by Congress in 2021.


Those enhanced subsidies, which expired in 2025, provided financial help to Americans with higher incomes and further lowered the cost of Obamacare for low-income people. Enrollment more than doubled, reaching an all-time high of 24.3 million in 2025.

Yet as enrollment spiraled upward, so did premiums. Prices reached a new high in 2025, averaging $497 per month for a 40-year-old enrolled in the most popular plan.

What didn’t change dramatically was the age profile of enrollees. Although some young adults entered the market in the era of enhanced subsidies, their numbers never exceeded the 2014 rate of 28 percent.

And despite a rise in the number of insurers doing business in Obamacare, some of the largest companies have said that they find it unprofitable.

David Joyner, CEO of CVS Health, testifying before Congress on Jan. 22, said its costs exceeded income in the Obamacare marketplaces in 2025, and Gail Boudreaux, CEO of Elevance Health—the parent company of Anthem—said it did not turn a profit from Obamacare in 2025.

David Cordani of The Cigna Group said, “We lost money in the exchange all but two years since 2014.”
]]> Sat, 07 Feb 2026 17:18:00 GMT https://dennis-k.websitex5.me/blog/?skyrocketing-obamacare-premiums https://dennis-k.websitex5.me/blog/rss/000000012 <![CDATA[What Changed This Year: Subsidies and Marketplace Rules Explained]]> imblog Annual policy updates that affect premiums, subsidies, and plan shopping.]]> Fri, 23 Jan 2026 15:58:00 GMT https://dennis-k.websitex5.me/blog/?what-changed-this-year--subsidies-and-marketplace-rules-explained https://dennis-k.websitex5.me/blog/rss/00000000C <![CDATA[ACA Open Enrollment 2026: Key Dates and What You Need to Apply]]> imblog Important deadlines, required documents, and tips to avoid application mistakes.]]> Fri, 23 Jan 2026 15:58:00 GMT https://dennis-k.websitex5.me/blog/?aca-open-enrollment-2026--key-dates-and-what-you-need-to-apply https://dennis-k.websitex5.me/blog/rss/000000006 <![CDATA[Are Standalone Dental Plans Worth It? What to Look For]]> imblog
You’ve been all smiles about your dental health. Then, one day it hits you – a painful toothache. Suddenly it hurts to sip a glass of water, and you can barely focus on anything but the pain. Unfortunately, you know it won’t get better on its own. You need a dentist – and wonder how much it will cost you.

The answer depends on if you have dental insurance and what your dental insurance covers. Some dental insurance plans may just cover preventive care, but others may cover services like crowns and oral surgery.
If you’re wondering, “Do I need dental insurance?” The answer is you can get by without it, but doing so comes with some risk. It’s usually worth it to have dental insurance. Depending on your personal needs, you may not need a plan with the most comprehensive dental coverage. But whether or not you have dental insurance, you shouldn’t ignore problems with your mouth, teeth and gums. Oral health concerns can get worse without treatment and may lead to other costly medical problems.

Below we explain how dental insurance works and how having insurance can save you money in the long run.
For starters, here’s what you should know about dental insurance
Some types of insurance (like car insurance) are there in case something bad happens. But dental insurance, like health insurance, is designed to keep the worst from happening.

Here’s how dental insurance works: you pay a monthly amount (premium) and your plan covers some of the cost of your care during the year. Plans can vary based on the insurance carrier and their plan options. But dental insurance usually covers 100% of preventive dental care, like checkups, screenings and cleanings. Other services can have different levels of coverage.

Here are terms you should know.
  • Premium: The monthly payment to be enrolled in a dental insurance plan.
  • Deductible: The dollar amount you’ll need to pay towards your dental care before your benefits begin for the year – for dental plans, this amount is usually between $25-$75. Preventive services are covered even before you reach your deductible.
  • Coinsurance: The percent of the cost you pay for dental services after you’ve met your deductible. For example, your coinsurance for a root canal may be 20% or 50% of the cost.
  • Annual maximum: The most your dental plan will pay for your dental care in a single year. After this point, you’re responsible for 100% of the dental expense.
Is dental insurance worth it? How dental insurance pays for itself
If you keep up on your preventive care appointments, dental insurance usually pays for itself. And, if you need additional dental care, you’ll definitely see the value of having a plan.
To understand what an investment in dental insurance looks like, let’s start by examining monthly premiums. If you pay $40 each month, that equals $480 per year.
With this investment, you usually get two checkups covered at 100% each year, although that may vary based on coverage. Dental providers also negotiate fees with insurers, decreasing overall cost. Without insurance, these two visits alone typically cost up to $400 or $500 out of pocket. But the value of dental insurance usually doesn’t stop there – since most plans cover at least a portion of the cost of dental services like fillings and root canals.
Dental insurance can also make it less likely that you’ll need advanced dental care. Here’s why: given the cost of preventive care, you may skip it if you didn’t have dental insurance. But regular preventive checkups help keep your mouth, teeth and gums healthy, decreasing your risk of developing serious oral health problems that can be painful and expensive to treat. And since your oral health is tied to your overall health, a dentist may also be the first to identify other health conditions such as oral cancer or diabetes.

Learn more: Wondering about coverage after retirement? See if dental insurance is worth it for seniors.
Dental care without insurance:
The costs quickly add up
Dental service costs can often be difficult to predict. While there are averages you can expect, it depends on the complexity of your procedure and what materials are used. That’s why dental insurance is important. It can help you cover a chunk of these costs so you don’t have to pay out of pocket.

For example, if you need one crown that normally costs $1,200, your dental plan’s negotiated fee with network dental clinics could be reduced to around $900. If your plan has a 50% coinsurance on crowns, you will pay $450, and the dental plan would pay $450. This means you could save $750 on that one crown. But let’s say you need more dental work during the year – a crown, root canal, or some other specialty service – your costs are likely to jump by $1000 or more.
Average cost of dental services and how insurance can help

ProcedureAverage cost without insurance*Typical dental insurance coverage**Routine checkups$50 – $350+100% for preventive careX-rays$40 – $850+100% if considered preventiveFillings$200 – $600+50 to 80% after deductibleExtractions$140 – $830+50 to 80% after deductibleRoot canals$600 – $1,200+50% after deductibleDental crowns$800 – $2,500+50% after deductible
*Average costs of procedures without insurance can vary depending on where services were provided, what materials were used and the complexity of a patient’s needs.
** Coverage may vary depending on plan
How dental insurance helps you budget
Dental insurance makes dental health care costs more affordable and predictable – both essential elements of maintaining a budget. Your dental plan will typically list coverage details upfront, letting you know exactly what you’ll be expected to pay and when for each type of service. This allows you to avoid surprise expenses, so you can create a comprehensive budget for the year.

Your dental insurance plan will help you budget by:
  • Covering a portion of your service costs, from routine to emergency care, so you pay less
  • Clearly outlining out-of-pocket costs like your monthly premium, deductible and cost-sharing amounts per service
  • Covering the cost of preventive services, which helps you detect possible issues early so you can avoid future expenses

  • Average cost of dental services without insurance
  • Routine checkup: A preventive appointment that includes teeth cleaning by a dental hygienist and a dental exam can cost between $80 and $400. Insurance usually covers 100% of the cost, even before you meet your deductible.
  • Fillings: Prices fluctuate depending on size, location and the type of filling material used. The average cost of a filling is $140 to $200, but in more severe cases, that cost can rise to around $500. Insurance may cover 50% to 80% of the cost.
  • Tooth removal (extraction): A simple extraction usually costs between $75 and $300 per tooth. The price can go up to several thousand dollars if the procedure is complicated – like if your tooth is stuck (impacted) or broken, or if you’re having your wisdom tooth removed. Insurance may cover 50% to 80% of the cost.
  • Crowns: A typical dental crown can cost between $1,100 and $1,500. This cost depends on variables such as crown type, treatment and any additional services required to do the procedure, like bone grafts or root canals. Insurance may cover 50% to 80% of the cost.
  • Root canals: You can expect to pay between $700 and $2,100 for a single root canal, though factors such as location of the tooth, and the need for emergency care can affect (and increase) price. Insurance may cover 50% to 80% of the cost.
]]> Fri, 23 Jan 2026 15:58:00 GMT https://dennis-k.websitex5.me/blog/?are-standalone-dental-plans-worth-it--what-to-look-for https://dennis-k.websitex5.me/blog/rss/00000000A <![CDATA[Medicare Supplement vs Medicare Advantage: Pros, Cons, and Costs]]> imblog
If you're age 65 or about to turn 65, you may be wondering: Is regular Medicare enough for my needs? Do I need supplemental insurance?

Medicare Parts A and B, also known as original Medicare, provide good basic health coverage. But they don’t cover everything. Roughly 81% of traditional Medicare enrollees have some form of supplemental coverage.1 One reason is that Medicare only pays part of your health care costs—you pay the rest in the form of deductibles, coinsurance, and copayments. And with Medicare, there’s no limit on what you spend out of pocket. That means a single extended hospital stay could become an enormous financial burden.

Also, there are some things original Medicare doesn’t cover at all, including dental care, vision care, and long-term care (unless medical care is needed). Paying for these services on your own can get very expensive, very quickly.
Medicare Advantage and Medigap supplemental insurance are two ways to fill Medicare coverage gaps and control your costs. You can't sign up for both types of coverage at once. That's why it's important to know how these plans work, the differences between the two, and the pros and cons of each.

What is Medicare Advantage?
Medicare Advantage, also known as Part C, is a way for older adults to receive original Medicare coverage from private health plans instead of directly from the government. The most common types of Medicare Advantage plans are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-For-Service (PFFS) plans. To join a Medicare Advantage plan, you must be enrolled in Medicare Parts A and B.
Medicare Advantage plans must cover the same services offered under original Medicare, but they may also bundle that coverage with additional services original Medicare doesn't cover. Many Medicare Advantage plans also include coverage for prescription drugs (Part D). Most Medicare Advantage plans require cost sharing in addition to monthly premiums, typically in the form of copayments and/or deductibles.

What are the pros of Medicare Advantage?
  1. There’s a cap on out-of-pocket costs: In 2025, the Part C out-of-pocket maximum is $9,350. Individual Medicare Advantage plans can set lower limits if they wish. Once you reach the out-of-pocket limit, your plan pays 100% of covered health services for the rest of the calendar year. If your income is limited and you value predictability, a cap on out-of-pocket costs can give you peace of mind.
  2. You may be able to get coverages not provided by original Medicare: Medicare Advantage plans cover hospital services and doctor visits just like original Medicare. But they may also provide benefits not included with regular Medicare, such as vision, hearing, dental, fitness classes, and medically necessary transportation. Select plans also offer non-medical benefits like assistance with utility bills and pre-paid debit cards to purchase healthy foods.
  3. All your coverages are rolled into one plan: Many Medicare Advantage plans offer the convenience of having your hospital, medical, and prescription drug coverage combined into a single plan. This means you won’t have to purchase a standalone Part D plan and pay a separate monthly premium.
  4. Your premiums may be lower: Medicare Advantage plans generally offer low monthly premiums (in addition to your Part B premium) or no-premium plans. This may cost you less per month than having original Medicare, Part D, and a Medigap policy. For 2025, the average Medicare Advantage plan premium is estimated at $17 per month. This may appeal to you if you like having lower up-front costs.
  5. You have options if you're not happy with your plan: Each year, you have two opportunities to change back to Original Medicare or switch Medicare Advantage plans. These are the Medicare Annual Open Enrollment Period (Oct. 15-Dec. 7) and the Medicare Advantage Open Enrollment Period (Jan. 1-March 31).

What are the cons of Medicare Advantage?
  1. You may be restricted in what providers you see: Original Medicare allows you to see any health care provider that accepts Medicare. But Medicare Advantage plans typically don’t give you that freedom of choice. Many of these private plans have a designated network of providers restricted to a member’s geographic area. Except for emergencies, some plans may not cover care outside of their defined service area—or they may impose higher cost sharing or prior authorization rules for out-of-network care.

    This limited access means you might not be able to see the best (or your preferred) providers when you have a need. It may also be challenging to find providers if you live in a rural area.

    What's more, with Medicare Advantage, you may have to get a referral from your primary care provider if you want to see a specialist. This extra visit translates into extra time and expense.

  3. You could end up paying more out of pocket. While the low monthly premiums of Medicare Advantage plans may be alluring, you risk paying more in the long run in the form of co-payments, deductibles, and other out-of-pocket costs. If you develop a serious illness or chronic condition, these costs can pile up quickly (and exceed what you’d pay with original Medicare).

    One study showed that 23% of retirees with Medicare Advantage Plans spent more than 10% of their income on health care costs—compared to just 17% of Medigap beneficiaries.2 Also, in its recent report on Medicare, Kaiser found that slightly fewer Original Medicare beneficiaries had problems paying for their health care than Medicare Advantage enrollees.3

What is Medigap and how does it work with Medicare and Medicare Advantage?
Medigap is additional insurance that can be purchased from private insurance carriers in each state. While Medicare Advantage is an alternative way to get your Medicare benefits, Medigap is purely supplemental. Its purpose is to bridge the “gaps” in your original Medicare coverage. You cannot use Medigap with a Medicare Advantage plan.
A Medigap plan is designed to reimburse you for the costs you pay out of your own pocket, such as deductibles, copayments, coinsurance, and more. The amount of reimbursement you receive depends on the type of plan you have.
Based on where you live, you can choose from up to 10 different Medigap plans: A, B, C, D, F, G, K, L, M, and N (Medigap plans in Wisconsin, Massachusetts, and Minnesota are named differently). Each type of Medigap plan provides a unique set of benefits. Note: Plans C and F are no longer available to people who first joined Medicare on or after Jan. 1, 2020. These plans are still in place for people who enrolled prior to that date.
It’s important to note that Medigap is an optional insurance policy. If you buy one, you must pay a monthly premium in addition to the monthly Part B premium you pay to Medicare.

What are the pros of Medigap?
  1. It can help make your out-of-pocket costs more predictable and affordable: Since Medigap provides reimbursement for some or all of your Medicare Part A and Part B copayments and deductibles (depending on your plan), you don’t have to worry about cost every time you visit a doctor or hospital. Most Medigap plans cover the Medicare Part A hospital deductible, which is $1,676 in 2025. Should you experience a health emergency or extended hospital stay, Medigap coverage can save you a significant sum.

  2. You may be able to get coverages not provided by Original Medicare: For example, standard Medigap plans C, D, F, G, M, and N provide emergency health coverage when you take a trip outside the U.S. This is a valuable benefit if you travel abroad frequently. A small number of Medigap plans also offer other nontraditional benefits such as dental, vision, and hearing.

What are the cons of Medigap?
  1. It can be expensive: Medigap premiums vary greatly, ranging from as little as $30 to $40 per month all the way up to $400 or more per month. In general, you can expect to pay less for Medigap plans with less coverage. Some plans also have cost sharing in addition to premiums.

  2. Prescription drugs are not covered: Medigap policies do not cover prescription drugs, so you must enroll in and pay for a separate Medicare Part D plan.

  3. It’s not easy to switch plans: The best time to buy a Medigap policy is during your six-month Medigap Open Enrollment Period. This period automatically begins the first month you have Medicare Part B and you're age 65 or older. Once this enrollment period is over, you may pay more for a Medigap policy—or you may be denied coverage outright—if you don’t meet the carrier’s medical underwriting guidelines. Note: If you live in Connecticut, Massachusetts, Maine, or New York, you may be able to buy a Medigap policy beyond your enrollment period without answering underwriting health questions.
]]> Fri, 23 Jan 2026 15:58:00 GMT https://dennis-k.websitex5.me/blog/?medicare-supplement-vs-medicare-advantage--pros,-cons,-and-costs https://dennis-k.websitex5.me/blog/rss/000000008 <![CDATA[What to Include in Your Employee Census for a Group Health Quote]]> imblog A simple checklist and template to gather the right data for accurate group health quotes.
Employee Census
Information Gathered for quoting
Name,  Date of Birth, Contract type*, Member type**, zip code, gender, smoker Y/N

* Employee Type:
Employee only, Employee & spouse,  Employee family
** Member type:
Employee, spouse, children


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