Are you curious about the Medicare Advantage Program? New guidelines. New programs. New regulations. If you’re feeling a little confused, you’re not alone. That’s why it’s time for a Senior Assistance Club Guide.
In this overview, you’ll learn the most important facts about the Medicare Advantage program. You’ll discover the pros, the cons, and key insights to give you a head start on understanding the landscape.
Let’s dive in.
Medicare Advantage is a plan that’s a private health insurance plan, approved by Medicare. You can choose to get your Part A, Part B, and D benefits from Medicare Advantage Part C coverage instead of traditional Medicare.
I don’t know about you. But I like to refresh my mind with a quick review of a ‘glossary’ of terms.
As a Medicare private insurance plan, Medicare Advantage plans usually have an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) network of doctors providing care. Members get their care from this network of doctors and hospitals.
Medicare Advantage policies are not Medigap plans. They work in different ways. Simply, they pay instead of Medicare, not after Medicare.
Depending on your lifestyle and personal preferences, you may find Medicare Advantage plans attractive — or not.
There are three types of Medicare Advantage Part C plans: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-for-Service (PFFS) plans.
Health Maintenance Organizations (HMOs) require you to use in-network providers, except in emergency situations. You will likely need to select a primary care physician (PCP) who will coordinate your care. You may need to get a referral from your PCP in order to see a specialist.
Preferred Provider Organizations (PPOs) also have in-network providers, but you can see out-of-network providers as well. You may not need to select a PCP, but you may need to get a referral in order to see a specialist.
Private Fee-for-Service (PFFS) plans allow you to see any Medicare-approved provider that accepts the plan's terms and conditions. You do not need to select a PCP or get referrals to see specialists.
When choosing an insurance for older adults, it's important to consider your needs and budget. Make sure to compare the premiums, deductibles, co-pays, and coverage of each plan before making a decision.
You can enroll in a Medicare Advantage Type C plan during the annual Medicare open enrollment period. You can also switch to a different Medicare Advantage Type C plan during this time. If you have a Medigap policy, you may need to cancel it when you enroll in a Medicare Advantage Type C plan.
To enroll, you will need:
If you have questions or need help enrolling in a Medicare Advantage Part C plan, you can contact the plan directly or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Medicare has different parts.
Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
Part B covers outpatient doctor visits, preventive services, durable medical equipment, and some home health care.
Medicare Advantage Part C plans may cover:
Medicare Advantage Part C plans must cover all of the same benefits as Original Medicare Part A and Part B, but they can also offer additional coverage and may also have lower out-of-pocket costs than Original Medicare.
The amount you pay for a Medicare Advantage Part C plan depends on the specific plan you choose. You will still need to pay your Part B premium, as well as any deductibles, copayments, and coinsurance required by your plan.
You may also need to pay a monthly premium for your Medicare Advantage Part C plan. The amount of the premium varies by plan and can change each year.
Medicare Advantage Plans often offer more benefits than you’d receive under the Original Medicare. This varies amongst plans, so be sure to review options directly. The additional coverage may include routine vision care, hearing aids, routine dental care, prescription drug coverage, and fitness center membership.
When enrolling in a Medicare Advantage plan, you’ll continue to pay your Medicare Part B premium, plus an additional premium. This varies from one plan to another. Some plans offer premiums as low as $0.
Maximum out-of-pocket expenses are limited. Once you’ve spent the maximum amount, you’ll not have additional covered medical services for the remainder of the year.
Often a Medicare Advantage plan can be less expensive compared to staying on Original Medicare.
Coordination of care can be a huge convenience and a valuable asset for peace of mind. Typical plans have networks of contracted health care providers, often with a Primary Care Physician, who helps coordinate your care.
You might prefer working with one plan administrator. Most Medicare Advantage plans combine medical and Part D prescription drug coverage. A one-stop approach also coordinates the delivery of added benefits, such as dental, vision, and hearing care.
With Medicare, you can usually go to doctors and facilities that accept Medicare. However, Medicare Advantage plans are more restrictive. You are covered by terms that apply to their provider networks.
If you go outside of the network, your plan may not cover costs. Additionally, your costs may not apply to your out-of-pocket maximum.
To prevent misuse, Medicare Advantage plans often require prior authorization for services such as hospital stays, home health care, medical equipment or complex procedures. The plan may require a referral from your primary doctor to see specialists. This can create a cumbersome and tedious process in order to guarantee services are covered.
Most plans work with regional networks of participating providers. This means that you must reside in the specific advantage plan’s service area for at least 6 months of the year.
If you travel frequently and divide your time among different regions, this requirement may be problematic or prohibitive.
With over 4,700 Medicare plans nationwide, you have a lot of options to consider. You may want to do some initial research online. Simply start by typing in your zip code to explore plans that are available in your area.
If you are considering Medicare Advantage plans, talk with your friends, families, and colleagues. Get a realistic sense of what works, advantages, disadvantages, and whether their choices will truly work for you.
Additionally, experts recommend that you interview a licensed insurance agent about different plans in your area. You may have specific health care needs that direct your choices.
The bottom line? Medicare Advantage plans may provide more affordable coverage than the Original Medicare. However, you will need to meet the plan’s rules to receive payment for services.
With a healthy bit of research, you’ll find the choice that best matches your personal needs and lifestyle.