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Medicare Advantage Plans Explained

Overview of Medicare Advantage

Medicare Advantage plans were designed by Congress to provide a lower-cost premium option than Medigap. They are also great for those who missed their open enrollment window for Medigap and cannot qualify due to preexisting health conditions, since Medicare Advantage plans have very little Medicare underwriting.

Medicare Advantage plans and Medigap plans ARE different. Medicare Advantage members get benefits from private insurance providers, as opposed to Medicare, despite it sometimes being called Medicare replacement insurance.

When you sign up for Medicare Advantage, you don’t permanently replace your Medicare plan. You are simply getting your insurance benefits from a private company. It’s important to note that when the Medicare enrollment period comes around again, you can get on an Original Medicare plan.

How Medicare Advantage Plans Works

A Medicare Advantage plan is a way to get Medicare benefits by joining a private Medicare insurance plan. When you do this, Medicare pays the Medicare Advantage provider a fee for your Medicare Part A and B benefits.

While you are signed up for your Medicare Advantage plan, you must stay enrolled in Medicare Part A and B. Medicare pays the Medicare Advantage company to take on your medical risk, and that is how the Medicare Advantage plans are funded.

At the time of treatment, you give your Medicare Advantage insurance card to your medical provider, and they will bill this plan instead of Original Medicare.

Medicare Advantage Network Types

Medicare Advantage plans set in place different rulesets you must follow. Most Medicare Advantage plans have HMO or PPO networks.

Medicare Health Maintenance Organization (HMO) networks generally require to treat only with network providers, except in emergencies. You will usually need to select a primary care physician. That physician can coordinate a referral if you need to see a specialist. There are some HMO plans that offer you the ability to see out-of-network providers in certain circumstances.

Medicare HMO plans are the most prevalent type of network.

Medicare Preferred Provider Organization (PPO) networks allow you to see doctors outside the network but you’ll have substantially higher out-of-pocket spending to do so.

Medicare Private Fee-for-Service (PFFS) is offered in limited counties and is being slowly phased out. These plans may or may not include Part D. How you access to care is also different.

Extra Benefits are Offered by Medicare Advantage Plans

Original Medicare doesn’t cover vision, hearing, dental, and wellness programs – like gym memberships – but Medicare Advantage Plans do. New benefits are being covered like transportation to doctor visits, over-the-counter drugs, adult day-care services, and other health and wellness services. One of the other features of a Medicare Advantage Plan is being able to tailor a benefits package to offer benefits relevant to your needs – for example chronically ill enrollees. Custom packages treat relevant conditions.

Every Medicare Advantage plan has its own list of benefits. No matter what plan you choose, it will offer all the same services as Original Medicare, including doctor visits, lab work, and surgeries.

A visit to your primary care doctor may cost you $10, while a visit to a specialist maybe $50. Some examples of when to expect higher co-pays include diagnostic imaging, hospital stays, and surgeries. Co-pays for these services will likely be several hundred dollars, but it varies greatly by state, so it’s best to review plans in your area for more details.

Enrollment Periods for Medicare Advantage

You may enroll in Medicare Advantage during your Initial Enrollment Period when you turn 65. After that, you can only enroll during certain times of the year. Once enrolled in Medicare Advantage, you must stay on the plan for the remainder of the calendar year. You can only dis-enroll during certain times of the year unless a special circumstance allows you to qualify for a special enrollment period.

The most common time to change your Medicare Advantage plan is during the Annual Election Period. This period runs every fall from October 15 through December 7. Any changes made to your plan will take effect on January 1.

If you choose to leave your Medicare Advantage plan and switch to Original Medicare, you must let your Medicare Advantage provider know, or else Medicare will continue to show that you are enrolled in your Medicare Advantage plan, not Original Medicare.

Medicare Advantage vs Medicare Supplement (Medigap)

The primary difference between Medicare Advantage and Medigap is that with Medigap, you can see any healthcare provider that accepts Medicare. With an Advantage plan, you have to find out if a provider accepts your specific Advantage insurance company.

Also, some Medigap plans have fuller coverage. Original Medicare pays for 80%, and a Medigap plan will cover some or all of the remaining 20% depending on which Medigap plan you choose. For example, with Medigap Plan G you will not have repetitive co-pays that you would experience with a Medicare Advantage plan.

Most Medicare Advantage Plans include drug coverage (Part D). Medigap plans do not include Medicare Part D coverage, so that must be bought separately. They also do not cover dental, vision, or hearing, while some Advantage plans cover at least a small part of this.

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