Medicare Advantage vs. Original Medicare for Cancer Patients in Florida

A cancer diagnosis is one of the most stressful events a person can face. The last thing you need is to discover that your Medicare plan does not cover your oncologist, your cancer center, or your chemotherapy drugs.

This guide is specifically for Florida Medicare beneficiaries who have been diagnosed with cancer -- or who want to plan ahead -- and need to understand which type of Medicare coverage best fits their situation.

Original Medicare (Parts A and B) works with virtually any doctor or hospital in the United States that accepts Medicare. There are no networks, no referrals, no prior authorizations for most services. You see the oncologist you want, at the cancer center you choose.

Medicare Advantage (Part C) is managed care. You have a network of providers. You may need referrals. You may need prior authorization before starting chemotherapy, radiation, or certain procedures. Out-of-network care may cost significantly more -- or may not be covered at all.

For cancer patients, this distinction is not abstract. It is the difference between getting care at Moffitt Cancer Center in Tampa or Mayo Clinic in Jacksonville -- and being told those facilities are out of network.

Florida has world-class cancer centers:

• Moffitt Cancer Center (Tampa) -- NCI-designated comprehensive cancer center
• Mayo Clinic (Jacksonville) -- nationally ranked oncology program
• UF Health Cancer Center (Gainesville)
• AdventHealth Cancer Institute (Orlando)
• Baptist Health Miami Cancer Institute
• Cleveland Clinic Florida (Weston)

With Original Medicare + Medigap: You can go to any of these centers. No referral needed. No prior authorization for most services. Your Medigap plan covers the 20% coinsurance that Original Medicare does not pay.

With Medicare Advantage: You must verify that your specific plan includes the cancer center in its network. Many HMO plans do not include Moffitt or Mayo Clinic. PPO plans may cover them as out-of-network providers -- but at significantly higher cost-sharing.

Medicare Advantage plans frequently require prior authorization for:

• Chemotherapy drugs
• Radiation therapy
• Surgical procedures
• Specialty drugs
• Inpatient hospital stays
• Certain imaging (PET scans, MRIs)

Prior authorization delays can be significant -- days or weeks -- during which treatment is on hold. Studies have shown that Medicare Advantage beneficiaries with cancer experience more prior authorization denials and delays than Original Medicare beneficiaries.

Original Medicare does not require prior authorization for most cancer treatments. Your oncologist orders the treatment; Medicare pays its share.

With Plan G, once you pay the $283 Part B deductible, you pay nothing for covered Medicare services for the rest of the year. For a cancer patient undergoing chemotherapy and radiation, this is extraordinarily valuable.

A cancer patient on Medicare Advantage could hit their out-of-pocket maximum quickly -- but that maximum can be $5,000-$9,000 or more. And that is assuming all care is in-network.

Many modern cancer treatments are oral chemotherapy drugs taken at home -- not infused in a clinic. These drugs are covered under Part D, not Part B.

This is critical because:

• Part B covers infused/injected chemotherapy (administered in a clinical setting)
• Part D covers oral chemotherapy drugs (pills taken at home)

Oral cancer drugs can cost $5,000-$15,000 per month at list price. The $2,100 annual Part D out-of-pocket cap (effective 2025-2026) is a game-changer for cancer patients on oral chemotherapy. Once you hit $2,100 in out-of-pocket drug costs, your plan covers 100% for the rest of the year.

Both Original Medicare (with Part D) and Medicare Advantage (MA-PD) plans are subject to the $2,100 cap. Make sure your specific oral chemotherapy drug is on your plan's formulary before enrolling.

Can you switch from Medicare Advantage to Original Medicare after a cancer diagnosis?

Yes -- during Annual Enrollment Period (October 15 - December 7) or Medicare Advantage Open Enrollment (January 1 - March 31). However, there is a critical catch:

Medigap medical underwriting: If you switch to Original Medicare and want to add a Medigap plan, insurers in most states (including Florida) can use medical underwriting outside of your initial enrollment period. A cancer diagnosis is a pre-existing condition that could result in denial or very high premiums.

The exception: If you are within your initial 6-month Medigap open enrollment window (when you first enroll in Part B), you have guaranteed issue rights -- no insurer can deny you or charge more based on health status.

This is why the plan you choose when you first become eligible for Medicare matters so much. Switching later, after a serious diagnosis, may not be possible at standard rates.

If you have been diagnosed with cancer or have a family history of cancer:

1. Choose Original Medicare + Medigap Plan G when you first become eligible. The guaranteed issue window is your one opportunity to lock in comprehensive coverage regardless of health status.

2. Add a standalone Part D plan to cover oral chemotherapy and other medications.

3. Verify your oncologist and preferred cancer center accept Medicare -- virtually all major Florida cancer centers do.

If you are already on Medicare Advantage and receive a cancer diagnosis:

1. Immediately verify your oncologist and cancer center are in-network
2. Check your plan's prior authorization requirements for chemotherapy and radiation
3. Review your out-of-pocket maximum -- understand the most you could pay
4. Consider switching to Original Medicare + Medigap at the next Annual Enrollment Period, but be aware of Medigap underwriting challenges

For cancer patients, Original Medicare with Medigap Plan G is almost always the superior choice. The freedom to see any oncologist, access any cancer center, and face zero cost-sharing after the $283 deductible provides both financial protection and peace of mind during an already difficult time.

Medicare Advantage's $0 premium is appealing -- but when you are facing cancer treatment, the network restrictions, prior authorization requirements, and potential out-of-pocket costs can far outweigh the premium savings.

Facing a cancer diagnosis and unsure about your Medicare coverage? Call William Gray at (386) 871-3858 or schedule a free consultation. William helps Florida cancer patients and their families navigate Medicare coverage so they can focus on what matters most -- getting well.