What are Medicare Advantage Plans?

Medicare Advantage plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide all your Part A and Part B benefits. Advantage plans are sometimes called Medicare Part C. Common types of Medicare Advantage plans include:

  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Private-Fee-for-Service (PFFS)
  • Special Needs Plans (SNPs)

What is Medicare Part C?

Medicare Part C
Happy Senior saves money with Medicare Part C

Medicare Advantage Plans, sometimes called Medicare Part C is offered by private companies enrolled by Medicare. In order to enroll in a Medicare Advantage Plan, you must first be enrolled in Medicare Part A and Part B. Consequently, you will still pay Medicare Part B monthly premium. When you enroll in Medicare Part C, you receive all of your Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) coverage.

Medicare Part C is an alternative to having a Medicare Supplement Plan and Part D plan. In other words, you can not have Medicare Advantage Plan (Part C) and Medicare Supplement Plan. An Advantage Plan is similar to a group plan you had when you were working. Advantage Plans have specific network of hospitals and doctors from which you receive health care benefits.

Medicare Part C gives Medicare beneficiaries a lower-premium option than Medigap. Moreover, Part C has very little Medicare underwriting. The only medical condition that can disqualify you is kidney disease. In particular, being diagnosed with End-Stage Renal Disease. All other health conditions are accepted. Therefore, if you missed open enrollment period for Medigap and you cannot qualify for Medigap due to health conditions, Medicare Part C can be great option for you. On the other hand, if you are in open enrollment and you chose an Advantage Plan, you may not be able to qualify for a Medigap plan later.

Medicare Advantage Benefits

The private company you chose will be the one that manages your health plan benefits (not the government). When you enroll in Advantage Plan, you no longer get benefits from original Medicare. Instead, your health care providers will sent their bills directly to your Medicare Advantage insurance company. Therefore, you should file your red, white, and blue Medicare care in a safe place. You don’t want to accidentally present it to a provider as means of payment because doing this would result in denied claims. In other words, Medicare is not directly paying for your claims because they are paid by your Medicare Advantage company. Therefore, you should present your Advantage Plan ID card to your health care provider.

Your advantage plan monthly premiums vary based on the health plan you chose. For instance, some plans have a zero dollar Advantage Plan premium. On the other hand, companies have different rules for how you get services. For instance, some companies may need you to get a referral to see a specialist. Moreover, you may only go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care.

When you have a doctor appointment, hospitalization, or procedure, you will have a set co-payment or co-insurance amount to pay. As a result, costs maybe more predictable. Moreover, you pay no deductible and coverage beyond original Medicare parts A and B include drugs, dental, vision, and hearing coverage. In addition, some Advantage plans may offer Worldwide Emergency Coverage including:

  • Urgent care
  • Emergency room
  • Inpatient hospitalization
  • Emergency transportation

Your most important benefit of Medicare Advantage Plans maybe the annual limits on out-of-pocket expenses. In exchange for lower premiums of Advantage plans, you agree to certain network restrictions of HMO or PPO.

Medicare Advantage Plans

In most Medicare Health Maintenance Organization (HMO) plans you receive care and services from doctors, hospitals, and other healthcare providers in your plan’s network. However, you can get out-of-network coverage for emergency care, urgent care, and dialysis. You will need to select a primary care physician. That physician will coordinate a referral if you need to see a specialist. In most cases, prescription drugs are covered in HMO plans.

Medicare Advantage Plans network
Medicare Advantage Plans use a network of doctors

Medicare Preferred Provider Organization (PPO) plans allow you to see doctors outside the network. However, you will have substantially higher out-of-pocket spending to do so. In other words, PPO plans gives you flexibility to go to doctors, specialists, or hospitals that are not on the plan list, but it will usually cost more. If you want Medicare drug coverage, you must join a PPO plan that offers prescription drug coverage. Otherwise, you will not have prescription drug coverage because you can not join Medicare Part D (prescription drug plan). PPO plans do not require you choose a primary care doctor. Furthermore, in most cases you do not need a referral to see a specialist in PPO plans.

A Medicare Private Fee-For-Service (PFFS) plans are less common and available in limited counties. Moreover, PFFS plans may or may not include drug coverage. In a PFFS network you can see any of the network providers. In addition, you can also choose an out-of-network doctor, hospital, or other provider. However, your cost will usually be lower if you stay in network. PFFS plans do not require you to choose a primary doctor. You also do not need to get a referral to see a specialist in PFFS plans.

When choosing a Medicare Advantage network, it is important that all of your providers are in network (not just doctors). For instance, if you have durable medical equipment or home health care provider, you need to make sure that provider is in your network.

Special Needs Plans (SNP)

Medicare Special Needs Plans (SNP) limit membership to people with specific diseases or characteristics. SNPs tailor their benefits, provider choices, and drugs to best meet the specific needs of the groups they serve. In most cases, you must get your care and services from doctors or hospitals in the Medicare SNP network. However, you can receive out-of-network care for emergency or urgent care from a sudden illness or injury. Likewise, you can receive out-of-area dialysis if you have End-Stage Renal Disease (ESRD). All SNPs provide prescription drug coverage. In most cases, SNPs may require you to have a primary care doctor. Otherwise, the plan may require you to have a care coordinator to help with your health care. If you need to see a specialist, you will need a referral. However, you do not need a referral for annual mammogram screening and in-network pap test and pelvic exam.

Medicare Advantage Enrollment Periods

Medicare Advantage plans have lock-in periods. Your initial enrollment period starts when you first turn 65. After that, you may enroll or dis-enroll only during specific times of the year. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year. The Annual Election Period is when you can change your Medicare Advantage plan. This period runs from October 15th thru December 7th each fall. Any changes you make will take effect January 1.

Medicare Advantage plan calendar clock
Annual Election Period for Medicare Advantage Plans is October 15th – December 7th.

Medigap vs Medicare Advantage

Medigap is Medicare Supplement plan which pays the 20% co-insurance expense of Medicare Part B and the deductible of Part A ($1408 in 2020). In addition, Medigap covers your co-pays for hospital stays, skilled nursing facility care, hospice and home health care. Most important, Medigap has a one-time open enrollment period that does not require medical underwriting. For example, if you are healthy at 65, you may decide not to get supplement coverage. Then a few years later you may develop a health condition and try to get a Medigap plan to pay for all the expensive medical treatments. In this case, you will be dismayed that you now have to answer health questions and Medigap company can decline your application.

There are a number of difference between Medigap and Medicare Advantage. For example, Medicare Advantage has a smaller, local network of providers. While Medicare network has over 800,000 providers nationwide. Medigap does not change their benefits from year to year. So you don’t have do as much homework. For instance, you will not have to review upcoming benefit changes like you will on an Advantage plan. Medigap plans have fuller coverage on the back end. Medicare pays 80% and Medigap plan 20%, so you have little out of pocket. Furthermore, you will not have repetitive copays that you will on Medicare Part C.

For Medicare Advantage plans call Senior Healthcare Direct at 1-855-368-4717 or get a quote.