Medicare Open Enrollment, which runs from October 15 through December 7, will look different this year for 50,000 or so Vermonters whose Medicare Advantage (MA) plans – UnitedHealthcare and Vermont Blue Advantage – will no longer offer coverage in Vermont in 2026*. For the majority of these individuals, there is one choice for Medicare coverage: traditional Medicare, an excellent option that, in key ways, offers more flexible coverage than Medicare Advantage plans.
Traditional Medicare and MA plans are regulated by the Centers for Medicare & Medicaid services (CMS). Traditional Medicare is accepted by most hospitals and doctors in the United States, giving patients the freedom to choose where and from whom they receive care. Unlike traditional Medicare, MA plans are offered by private insurance companies who contract with Medicare to provide health coverage.
It’s important to note that plan holders will be automatically enrolled in traditional Medicare for 2026 unless they opt to make changes during Open Enrollment or the guaranteed issue enrollment period. Please visit the Vermont Department of Financial Regulation for more information about guaranteed issue rights.
If you’ve seen advertisements for MA, you know that some plans make a persuasive case with dental, vision, and hearing care benefits, coverage for prescription drugs, more affordable monthly premiums, and limits on annual out-of-pocket expenses. The monthly out-of-pocket cost for Medicare Advantage plans is generally lower than for traditional Medicare. The caveat – and unknown factor with MA plans – is that they often offer more restrictive coverage.
Traditional Medicare does not require referrals or prior authorization under most circumstances, so you don’t have to wait to receive the care that your doctor recommends. It also does not have a provider network, meaning you can visit any doctor or hospital in the U.S. that accepts Medicare. Most do. Many MA plans have geographical network limits, and you may be responsible for the cost of seeing a provider who is out-of-network for non-emergency care. The good news for Vermonters whose Medicare Advantage plans will no longer be offered in Vermont next year is that providers currently covered by these MA plans – including UVM Health Network and Dartmouth Health, among other hospitals – often accept traditional Medicare. In addition, with traditional Medicare, you gain access to providers and specialists out of state, including at major academic medical centers in Boston, who might have previously been out of network with your Medicare Advantage plans.
Certainly the news that UnitedHealthcare and Vermont Blue Advantage will stop offering coverage in 2026 came as a surprise to many beneficiaries; the cost difference between traditional Medicare and Medicare Advantage plans can be steep. While the benefits and out-of-pocket savings for MA plans can be a major draw, the money you save for a dental visit, for example, can be overshadowed by navigating prior approvals and denied claims and the costs associated with out-of-network care or care that exceeds the coverage threshold. We can’t always predict what our medical needs will be in a given year, but if it’s possible you need more intensive care now or may in the future, this is an important consideration.
Providers build trust with their patients, and often the two work together to decide on a plan of care that aligns with their healthcare goals. Medicare Advantage uses cost management tools like prior plan approvals which give the private insurance company that manages your Medicare Advantage plan the power to decide if the care your physician recommends is medically-necessary. Medicare Advantage is required to provide coverage for all services covered under traditional Medicare, but its more restrictive policies and practices can make it more cumbersome to access this coverage. Insurers that offer Medicare Advantage plans have come under scrutiny in recent years for an increase in denied prior authorizations, particularly when care recommendations come with a higher price tag, as with post-acute care like skilled nursing facilities.
Small, home-based care providers like CVHHH are also affected. Medicare Advantage insurers do not reimburse our agency for cost of care at the same rate as traditional Medicare. CVHHH is a Medicare-certified agency, and, thanks in large part to the communities that support us, we’ve been able to consistently provide care despite clawbacks in Medicare funding. As the Medicare funding landscape becomes more challenging, and as Advantage plan enrollments grow, CVHHH feels this strain. Our mission is to provide high quality, medically-necessary home health and hospice care to community members regardless of their ability to pay. We will continue to do so regardless of changes to the health insurance landscape in Vermont. These goals are reflected in America’s health care reform initiatives, and in the principles that helped create Medicare sixty years ago. Simply put, healthcare is personal, and people need to be able to trust that it will be there when they need it most. Changing plans can be disruptive, and being able to count on care and coverage is essential. That’s why we advocate for traditional Medicare.
If you have questions about your new insurance, adding Plan D prescription drug coverage to your plan, or where to get started, visit medicare.gov, call the Medicare helpline at 1-800-MEDICARE (633-4227), or contact your local State Health Insurance Program (SHIP) through the State of Vermont’s Department of Disabilities, Aging and Independent Living.
*Humana Medicare Advantage is the only insurer currently offering Medicare Advantage coverage in Vermont.
