Edited by John Leach
Last Updated April 13, 2022
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If you want more coverage than Original Medicare provides, consider enrolling in a Medicare Advantage plan —but be sure to compare all your options.
A Medicare Advantage plan, sometimes called Medicare Part C or an MA Plan, is one option for getting your Medicare health coverage. You can think of Medicare Advantage plans as “all-in-one” alternatives to Original Medicare. In addition to the original Parts A and B, the “bundled” Advantage plans often include Medicare Part D ( prescription drug coverage ) and sometimes extra benefits, like hearing, routine vision and dental, and wellness programs that can help lower your out-of- pocket costs.
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What Is a Medicare Advantage Plan?
Medicare Advantage plans are sold by private health insurance companies that must follow the rules set by the federal Medicare program. One benefit of these plans is that they all set a limit on what you’ll have to pay out of pocket each year for covered services, which helps protect you from unexpected expenses.
But beyond that, the details get kind of complicated. There are many different Advantage plans to choose from, and they don’t all work the same way. The costs and benefits vary by plan—a lower monthly premium comes with a higher deductible, for example—and not every plan is available in every location.
In most Advantage plans, to get the lowest cost, you need to use healthcare providers who participate in the insurance plan ’s network and service area. Some plans offer out-of-network coverage but at a higher cost.
Your Medicare health plan affects how much you pay for coverage, what services you get, what providers you can use, and your quality of care, so it can be a big decision. Before making a choice, it’s important to think about your anticipated healthcare needs and expenses, learn about all your Medicare coverage choices, and shop prices in your area.
Am I Eligible to Enroll in a Medicare Advantage Plan?
You’re eligible if you:
- Have Medicare Part A and Part B
- Are a U.S. citizen, U.S. national, or lawfully present in the U.S.
- Live in the service area of the Medicare Advantage plan you’re considering
- Do not have end-stage renal disease (with some exceptions)
You can join a Medicare Advantage plan even if you have a pre-existing condition.
What Do Medicare Advantage Plans Cover?
While there are many types of Medicare Advantage plans with different benefits, they cover all Part A and Part B services as well as emergency and urgent care. But plan details vary beyond that, so be sure to carefully research your options and what they cover.
- All MA plans have a yearly limit on what you pay out of pocket for Part A and Part B covered services. Once you reach your plan’s limit, you’ll pay nothing for Part A and Part B covered services for the rest of the year.
- Most Medicare Advantage plans include Medicare prescription drug coverage (also known as a Part D plan ), but be sure to confirm before choosing a plan. With certain types of plans that don’t include drug coverage (like Medical Savings Account Plans and some Private Fee-for-Service Plans), you have the option to join a separate Medicare prescription drug plan.
- Some Medicare Advantage plans offer additional benefits for vision, hearing, dental, and health and wellness programs.
- Unlike with Original Medicare, Advantage plans may require you to get a referral before seeing a specialist.
- Advantage plans generally don’t cover care outside the U.S. or non- emergency care you get outside your plan’s network.
What Are the T ypes of Medicare Advantage Plans?
There are several types of Medicare Advantage plan option with very different coverage benefits:
- Health maintenance organizations (HMOs ): You might find that HMO plans are the only type of plan available in your area. These plans usually require you to choose a primary care provider to oversee your medical care. And you must get all your non- emergency care (like doctor visits ) from providers within the plan’s network for the services to be covered. Most HMOs include Medicare Part D coverage for prescription drugs.
- Preferred provider organizations (PPOs ): While Medicare Advantage PPO plans let you see any doctor who accepts your plan, you pay less out of pocket when you use in- network providers. Most PPOs include Medicare Part D coverage for prescription drugs.
- Private fee-for-service plans (PFFSs): Medicare Advantage PFFS plans are less common. These plans let you use any provider willing to accept the terms of your plan, but not every provider who accepts Medicare accepts PFFS plans, and a provider can decide at every visit whether to accept the plan and agree to treat you.
- Special Needs Plans (SNPs): Special Needs Plans are only available to individuals who meet certain conditions, such as having a serious or chronic health condition, qualifying for both Medicare and Medicaid, or living in a nursing home or other facility.
- Another less common type of Medicare Advantage plan that may be available in your area is a Medicare Medical Savings Account (MSA) Plan.
Note that because Medicare Advantage plans are offered by private insurance companies, not all plan types may be available in all areas.
How Do Different Medicare Advantage Plans Compare To One Another?
The chart below highlights key differences between the most common plans and is followed by a list of questions for further consideration. As always, you need to read specific plan details carefully.
|Is my care covered if I go to a provider or hospital outside of my plan’s network?||Generally, no. For the lowest cost, you must stay within your plan’s network of providers. If you get healthcare outside the plan’s network, you may have to pay the full cost, which can be exorbitant.||You may be allowed to get some services out of network for a higher co-payment or coinsurance, but you must follow the plan’s rules, like getting prior approval for a certain service when needed. Also, the POS portion of the plan has a separate deductible.||In most cases, you can get your healthcare from any provider or hospital in the PPO Plan network. These plans also give you the choice of providers that aren’t on the plan’s list, but you’ll pay less if you go to a network provider.||You can go to any Medicare-approved provider as long as they accept the plan’s payment terms and agree to treat you. If your PFFS plan has a network, you can also see any network providers who have agreed to treat plan members. You can also choose out-of- network providers who accept the plan’s terms, but you’ll pay more. Before you get any health service, ask the provider to contact your plan for payment details and to accept the payment terms. An important exception is that emergency care is covered whether the provider accepts the plan’s payment terms or not.|
|Do I need a referral before seeing an in-network specialist?||Yes, generally, you need a referral for specialists, but standard preventative care, like mammograms, is an exception. Read your plan details carefully.||See HMO.||You can get care from specialists without a referral or prior authorization from another doctor. If you use in-network specialists, your costs for covered services will be lower than if you use non-plan specialists.||Not applicable|
|Is prescription drug coverage included?||Generally, yes, but be sure to confirm before enrolling. If you join an HMO that doesn’t include prescription drug coverage, you can’t get a separate Medicare prescription drug Plan ( Part D ).||See HMO.||Generally, yes, but be sure to confirm before enrolling. If you join a PPO that doesn’t include prescription drug coverage, you can’t get a separate Medicare prescription drug Plan ( Part D ).||Prescription drugs may be covered. If you want Medicare prescription drug coverage and it’s offered by your plan, you must get your Medicare prescription drug coverage from that plan. But if your PFFS plan doesn’t offer drug coverage, you can join a separate Medicare prescription drug plan.|
When comparing Medicare Advantage coverage options, you should also consider these questions:
- Is the monthly premium a good value? Some Medicare Advantage plans may have premiums as low as $0, but remember that you’ll still need to keep paying your Medicare Part B premium, along with any co-payments, coinsurance, or deductibles that your plan requires. And a lower premium usually means a higher annual deductible.
- Are you comfortable with the annual deductible amount?
- What are the initial coverage and out-of-pocket limits?
- Does the plan include additional benefits, such as routine vision or dental, hearing, or wellness programs?
- Does the plan include prescription drug coverage? Are your current medications included in the plan’s formulary or list of covered drugs? What are the co-payment and coinsurance costs for the drugs you take? (Note that the formulary is one of many plan details that might change year to year, in which case your Medicare plan will notify you.)
- If the plan has a provider network, are your current healthcare providers included? (Provider and pharmacy networks can also change at any time; your Medicare plan will notify you if necessary.)
- What is the plan’s star rating? Medicare evaluates plans based on a 5- star rating system each year, and the star ratings are one way to gauge a Medicare Advantage plan ’s performance. Each plan is given a rating from 1 to 5 stars, with 5 stars being the highest quality score.
What do Medicare Advantage plans cost?
Costs vary by location and plan. Each year, plans set the amounts they charge for premiums, deductibles, co-pays, and services. The plan (rather than Medicare) decides how much you pay for the covered services you get, and the plan can change these costs each year.
With a Medicare Advantage plan, you have to pay the Part B premium. In 2019, the standard Part B premium amount was $135.50 (or higher depending on your income). Some people with Social Security benefits pay a little less ($130 on average).
Medicare Advantage plans can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care.
When calculating your out-of- pocket costs with a Medicare Advantage plan, in addition to your premium, deductible, co-payments, and coinsurance, you should also consider:
- The type of healthcare services you need and how often you get them.
- Whether you go to a doctor or supplier who accepts assignment. “Assignment” means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.
- Whether the plan offers extra benefits that require an extra premium.
- Whether you have Medicaid or get help from your state with healthcare costs.
Because the plan costs can change every year, if you join a Medicare Advantage plan, it’s important to review annual notices you get from your plan, including:
- the “Annual Notice of Change” (ANOC), which states any changes in coverage, costs, service area, and more that will be effective starting in January. Your plan will send you a printed copy by September 30.
- the “Evidence of Coverage” (EOC), which gives you details about what the plan covers, how much you pay, and more. Your plan will send you a notice (or printed copy) by October 15, which will include information on how to access the EOC electronically or request a printed copy.
If you need coverage information about a particular service, drug, or supply, you can get a decision from your plan in advance and find out how much you’ll have to pay. This is called an “organization determination.” Sometimes you have to do this as prior authorization for the service, drug, or supply to be covered. You, your representative, or your doctor can request an organization determination.
You also have the option to ask for a fast decision based on your health needs. If your plan denies coverage, the plan must tell you in writing, and you have the right to an appeal. If a plan provider refers you for a service or to a provider outside the network but doesn’t get an organization determination in advance, this is called “plan-directed care.” In most cases, you won’t have to pay more than the plan’s usual cost-sharing but check with your plan for more information.
When Can I Enroll, Drop, or Switch Medicare Advantage Plans?
There are three key periods when you can make decisions about your Medicare coverage:
- Initial Enrollment Period: This is the seven-month period when you first become eligible for Medicare, beginning three months before the month you turn 65 and ending three months after the month you turn 65. If you sign up during the first three months of your Initial Enrollment Period, in most cases, your coverage starts the first day of your birthday month. However, if your birthday is on the first day of the month, your coverage will start the first day of the prior month. If you enroll the month you turn 65 or during the last three months of your Initial Enrollment Period, your start date for coverage will be delayed.
- General Enrollment Period: If you have Part A coverage and you get Part B for the first time during the General Enrollment Period ( January 1–March 31 each year), you can also join a Medicare Advantage plan at that time. Your coverage may not start until July 1.
- Open Enrollment Period: Between October 15 and December 7 every year, anyone with Medicare can join, switch, or drop a Medicare Advantage plan. Your coverage will begin on January 1, as long as the plan gets your request by December 7.
FAQ: Comparing Medicare Advantage
If you join a Medicare Advantage plan, you’ll still have Medicare, but you’ll get most of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage plan, not Original Medicare. However, if you’re in a Medicare Advantage plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.
Talk to your employer, union, or other benefits administrator about their rules before you join a Medicare Advantage plan. In some cases, you might be able to use your employer or union coverage along with your Medicare Advantage plan, but in other cases, joining a Medicare Advantage plan might cause you to lose your employer or union coverage for yourself, your spouse, and your dependents.
If you have a Medicare Advantage plan, you don’t need and cannot buy a Medicare Supplement Insurance Plan.
Conclusion: Research Is Your Best Tool
Medicare Advantage plans can be complicated, but doing your research and comparing prices could save you money and improve your care.
There’s no way around it—the complexities of these plans are daunting. The benefits, though, can be worth the hassle, especially if you expect a lot of healthcare expenses.
And don’t forget to compare plans and save money with the Insurify Medicare comparison tool. Uncover options in your area at no cost to you. Try it today!