For some of us age 65 or older, Original Medicare (Part A and Part B ) plus supplemental Medigap insurance provides all the healthcare coverage we need. However, others may want more benefits found in Medicare Advantage plans which technically fall under the heading of Medicare Part C.
The Medicare Advantage Option
Medicare Advantage plans provide Part A and Part B coverage as an alternative to Original Medicare. Medicare pays a fixed amount to private insurance companies, which provide benefits to each beneficiary enrolled in their plans. These companies must provide the same Part A and Part B benefits as Original Medicare but may also cover:
- Medications
- Fitness programs
- Vision, hearing and dental
- Transportation to doctor’s visits
- Services that promote health and wellness
Like Medigap supplemental insurance, most Medicare Advantage plans cap out-of-pocket expenses. In addition, enrollees may have lower monthly premiums and other costs than Original Medicare.
The Downsides
While Medicare Advantage plans provide extra benefits, there are some restrictions:
- A plan may allow access only to providers in their network. Original Medicare enrollees can see any doctor accepting Assignment.
- Some plans may permit access to out-of-network providers, but enrollees pay more.
- Medicare Advantage Plans often charge higher out-of-pocket costs for deductibles, copays and coinsurance.
- Some studies have shown that Medicare Advantage plans deny coverage more frequently than Original Medicare.
Different Types of Medicare Advantage Plans
Medicare Advantage Plans can differ in terms of how they offer benefits:
Health Maintenance Organization (HMO)
- An HMO requires enrollees to use providers in its network.
- Most of these plans offer drug coverage.
Preferred Provider Organization (PPO)
- A PPO also has its own network. As a result, rules for using out-of-network providers may be less strict, but it could cost more.
- PPO plans typically cover drug costs.
Private Fee-for-Service (PFFS)
- PFFS enrollees can see any provider approved by Medicare.
- Some PFFS plans offer drug coverage.
Special Needs Plan (SNP)
- SNPs customize provider coverage and drug benefits to fit specialized needs.
- SNPs vary in the ways they handle out-of-network coverage.
Medical Savings Account (MSA)
- Under an MSA, an enrollee deposits money into a special savings account to pay for medical expenses.
- MSA plans do not offer drug coverage, but enrollees must join a separate Medicare Part D drug plan.
Medicare Advantage Plan Costs
Medicare Advantage costs differ among plans. Insurers combine benefits to create offerings that differentiate themselves from their competitors.
Premiums
Some plans pay for all or part of an enrollee’s Medicare Part B premium.
Deductibles
Deductibles vary. Higher deductibles often allow for lower copays or coinsurance.
Copays and Coinsurance
Medicare Advantage Plans are not allowed to charge more than Original Medicare for some services like skilled nursing care or chemotherapy. Copays and coinsurance for out-of-network services can be higher for insurers with a dedicated network.
Sign-Up, Renewal and Change Periods
There are several options for Medicare beneficiaries to join, switch, drop or make changes to Medicare Advantage Plans. See the Medicare and You handbook for more details.
Initial Enrollment Period (When First Medicare Eligible)
It usually encompasses the seven months beginning three months before age 65, the 65th birthday month and three months after that.
General Enrollment (January 1 to March 31)
For Medicare beneficiaries who have Part A and are receiving Part B coverage for the first time during this period, a Medicare Advantage Plan can be joined with coverage starting July 1.
Open Enrollment (October 15 – December 7)
Medicare beneficiaries can join, switch or drop a Medicare Advantage Plan with coverage beginning January 1.
Medicare Advantage Open Enrollment (January 1 – March 31)
Those enrolled in a Medicare Advantage Plan can switch to another plan, drop a plan or return to Original Medicare.
Special Enrollment Period (Qualifying Life Event)
In most cases, a Medicare Advantage Plan goes from January to December. However, for people experiencing certain life events (moving or losing other insurance coverage), they may be able to join, switch or drop a Medicare Advantage Plan during the year.
How to Compare Medicare Advantage Plans
If you’re thinking about a Medicare Advantage Plan, first write down all your healthcare priorities. Items on the list could include:
- What known or potential medical conditions do you have?
- How much out-of-pocket cost can you afford?
- How do plans compare on the following items?
- Premiums
- Deductibles
- Copays
- Coinsurance
- Out-of-pocket caps
- Medication coverage
- Other services offered beyond Original Medicare
- Out-of-network options
- Helpline availability
- What is the insurer’s track record on denying requested treatment?
Also, if a specific service, drug or supply item is needed, ask if it is covered by the plan.
A Medicare Advantage plan could be right for you. But, first, it is essential to compare different Medicare Advantage plans. Second, compare these plans to Original Medicare with supplemental Medigap insurance and stand-alone Part D Drug coverage. Once you have completed this thorough analysis, you’ll be better prepared to choose the right plan.
You can learn more about Medicare Advantage plans by visiting the Medicare website or downloading the latest Medicare and Me handbook. Also, look for my future blog posts on Sixty and Me for more valuable Medicare information. For an even deeper dive, check out my Medicare eBook at Cantissimo Senior Living.
Let’s Have a Conversation:
What questions do you have regarding Medicare Advantage Plans? Have you used it for your health needs? Why did you choose Medicare Advantage over Original Medicare?
