Should I Stay with Traditional Medicare?
Posted in Eye Blog, Mount Vernon, Sedro-Woolley, Stanwood, Whidbey
By Jodi Hulst, Director of Revenue Cycle Management
Update: 10/2026:
Medicare open enrollment started on October 15 and will run through December 7. This is the window during which Medicare beneficiaries select their coverage for 2027. There are some big changes and we wanted to share a few bits of information.
- The biggest change is that Kaiser has pulled out of the Medicare Advantage market in Skagit, Whatcom and Island counties. That means 8800 enrollees from Kaiser alone are shopping for a new healthcare plan.
- In Skagit County, there are approximately eight plans across three payers to select from. We want our patients to be aware that our practice is not contracted with Devoted Health. We are continuing to contract with Humana and United Healthcare, the other two options.
- The large changes in the market do mean that Medicare enrollees can revert back to traditional Medicare and a supplemental plan without having to go through underwriting.
- We strongly recommend discussing your options with a licensed insurance broker or a community resource like SHIBA. They will help you to compare the premium rates but also the out-of-pocket costs for each of these options. Medicare Advantage plans often have high out of pocket copays for surgery, as one example. You will also want to check provider networks to be sure your primary care provider and/or specialist providers are contracted.
A Quick Guide to Help You Choose Medicare Options
Staying with Traditional Medicare
- Freedom to Choose Any Doctor
Traditional Medicare allows patients to see any provider nationwide who accepts Medicare — no network restrictions. Medicare Advantage plans often limit patients to HMO or PPO networks, meaning out-of-network doctors may not be covered or referrals may be required. - No Prior Authorizations for Care
Under Traditional Medicare, doctors decide what care is medically necessary — no insurance company approval required. Medicare Advantage plans often require prior authorization for tests, surgeries, and specialist visits, leading to delays or denials of necessary care. - Predictable Coverage and Transparency
With Traditional Medicare and a Medigap policy, patients have predictable out-of-pocket costs and standardized benefits. Medicare Advantage plans vary widely and can change coverage, copays, and limits every year. - Nationwide Coverage
Traditional Medicare coverage applies anywhere in the United States. Medicare Advantage plans usually restrict coverage to local or regional networks except for emergencies. - Access to Specialty Care
Specialists and major medical centers readily accept Traditional Medicare, but many do not accept Medicare Advantage plans. This is crucial for complex conditions like retinal disease, diabetes, or heart disease. - Lower Long-Term Risk
Traditional Medicare with Medigap may cost slightly more monthly but protects against large medical bills and avoids plan traps. Switching back later can be difficult since Medigap plans can deny coverage based on health conditions. - Simplicity and Stability
Traditional Medicare coverage is straightforward and managed by the government. Advantage plans are run by private insurers with complex rules, networks, and frequent changes.
What About Eye Care with Medicare?
- Step Therapy Restrictions on Retinal Medications:
Traditional Medicare covers all FDA-approved retinal injections (Eylea®, Vabysmo®, Lucentis®, Avastin®, etc.) based on your doctor’s medical judgment. Many Medicare Advantage plans require “step therapy,” meaning patients must first “fail” cheaper medications before the preferred drug is approved. These delays can lead to irreversible vision loss, especially in macular degeneration or diabetic eye disease. - Step Therapy Restrictions on Retinal Medications:
Traditional Medicare covers all FDA-approved retinal injections (Eylea®, Vabysmo®, Lucentis®, Avastin®, etc.) based on your doctor’s medical judgment. Many Medicare Advantage plans require “step therapy,” meaning patients must first “fail” cheaper medications before the preferred drug is approved. These delays can lead to irreversible vision loss, especially in macular degeneration or diabetic eye disease. - Prior Authorizations for Surgery and Treatments:
Traditional Medicare allows immediate scheduling for necessary eye procedures. Advantage plans commonly require prior approval for cataract or retina surgery, retina laser procedures and imaging (OCT, fluorescein angiography), and injections and diagnostic testing. These requirements often cause delays in time-sensitive care. - Coverage Predictability and Billing Transparency:
With Traditional Medicare + Medigap, your out-of-pocket costs are consistent and transparent. Advantage plans may introduce new copays, limits, or coverage changes each year — including limits on the number of injections or tests allowed. - Access to Specialists and Major Eye Centers:
Traditional Medicare is universally accepted by leading ophthalmology and retina centers nationwide. Many tertiary care centers and retina subspecialists do not participate in all Medicare Advantage networks — meaning patients may face referrals, higher costs, or outright denials. - Your Eye Care Team Controls Your Care:
Under Traditional Medicare, your ophthalmologist decides your treatment plan, not an insurance company. Medicare Advantage plans often require insurer approval for tests, surgeries, and medication changes — creating extra administrative hurdles that can delay care.
Action Steps To Take During Open Enrollment
- Review your Annual Notice of Change if you’re on an Advantage plan.
- Compare your current coverage with Traditional Medicare + Medigap.
- Check provider participation — ensure your doctors accept your plan.
- Review prescription coverage under Part D.
- Talk with your ophthalmologist or retina specialist before switching.
- Use Medicare.gov’s Plan Finder to verify coverage and costs.
Need more guidance? Visit Medicare.org for additional information.
Director of Revenue Cycle Management
