What is Medicare Advantage?
Medicare Advantage, Part C of Medicare, is a private health insurance option for Medicare beneficiaries. Each year, health insurance companies offer new plans or update their existing plans in the counties they serve. Advantage plans, like most Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans don't give you nationwide coverage. Coverage is regional.
People who choose Medicare Advantage vs. Original Medicare generally do so because they get more benefits. The key advantage to private health plans is their ability to offer more services, including prescription drug coverage, dental, vision, hearing, and much more.
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How Does Medicare Advantage Work?
When a Medicare beneficiary chooses to enroll in a Medicare Advantage plan, the plan takes over responsibility for the member's healthcare coverage. In other words, the Centers for Medicare & Medicaid Services (CMS) is no longer the primary payor for the beneficiary's care, and, Medicare Part A and Part B coverage rules no longer apply.
As you prepare to compare plans, it's important to understand that all Medicare Advantage plans must provide all of the coverage guaranteed by Medicare Part A and Medicare Part B. However, plans are not required to cover benefits in the same way. For example, Part A and Part B (e.g., Original Medicare) are private fee-for-service coverage. Medicare pays approximately 80 percent of all covered services, and the beneficiary pays the remainder as an out-of-pocket cost or with supplemental insurance (e.g., Medigap).
With Advantage plans, members pay monthly premiums and copayments when they use services. Depending on a member's use of healthcare services, their costs may be more or less than 20 percent.
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What Does Medicare Advantage Cover?
When comparing Medicare Advantage plans, it's important to know what plans cover. The good news is that all Medicare Advantage plans are required to provide the same basic healthcare services for inpatient care and outpatient care as Original Medicare (Parts A and B). That's the good news.
The bad news is that Medicare does not require plans to cover Part A and B benefits in the same way as Original Medicare. Specifically, plans may set their own copayments, coinsurance, and deductibles, and they are allowed to place limitations on services. For instance, a plan can require its members to get referrals from their primary care doctor.
However, unlike the Original Medicare, Medicare Advantage plans may add extra benefits, such as Medicare prescription drug coverage, and routine dental, vision, and hearing care.
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Why are Some Medicare Advantage Plans Free?
They seem to be everywhere, those zero-premium Medicare Advantage plans. But, are they really free?
Not a chance!
The bottom line is that Medicare Advantage plans that have a zero-dollar premium are plans that are fully covered by a Medicare beneficiary's Medicare Part B monthly premium. Plans with extra benefits that can't be covered by the beneficiary's Part B premium have an extra premium that the beneficiary must pay.
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What is the Best Medicare Advantage Plan?
With Medicare, one size does not fit all. What's best for your neighbor may not be good for you. The only way to figure out which Medicare Advantage plan is best is to look at your unique personal needs.
For many people, Medicare Advantage offers a combination of the best cost and the best coverage. For instance, people with employer retiree benefits that assist them with copayments and deductibles love Medicare Advantage. The same is true of most people with dual-eligible status (e.g., Medicare and Medicaid) in counties that offer SNP-D (Special Needs Plans for dual-eligible people) plans.
However, if you don't have financial assistance from a former employer or your state, Original Medicare, not Medicare Advantage, might be a better option. Even though most private health plans offer more coverage options than Original Medicare, those options could end up costing you a lot more money.
How To Choose The Best Medicare Advantage Plan
People often want to know, who has the best Medicare Advantage plan for 2021? Or, what is the highest-rated Medicare Advantage plan? There isn't a clear-cut answer.
Finding the best Medicare Advantage plan takes a little legwork. It's important to understand that plans are regional, not national. As a result, a plan your friend has and loves in the next county over from you may not be available where you live. You must research plans in your county.
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What are the Advantages and Disadvantages of Medicare Advantage Plans?
It's understandable why most people with Medicare would want to know what are the disadvantages of Medicare Advantage plans? After all, the advantage is easy to see. Plans are able to offer more services than Original Medicare. But, how do you quantify advantages and disadvantages when comparing plans?
It isn't easy.
There are many potential disadvantages to these plans. Most are subjective. Here they are:
- Most private insurance companies that offer Medicare Part C plans use network providers to cover a service area. This might be a disadvantage if your doctor or specialist is not in the plan's network of health care providers.
- Most HMO plans and some PPO plans require members to get a referral from their primary care doctor to use healthcare services (except emergency care).
- Most types of Advantage plans have copays or coinsurance when a member uses services. Original Medicare also has a coinsurance requirement (20%), but Advantage plan copayments frequently cost more.
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What is the Difference Between Medicare Advantage and Medicare Supplement?
When comparing Medicare Advantage with Original Medicare, it's important to remove the fluff and look at the hardcore facts. Major healthcare, which is what Original Medicare covers, is very expensive. So, make sure those costs are covered as completely as possible within a budget you can afford.
The big difference between Medicare Advantage and Original Medicare plus a Medigap policy is when you pay. With Medicare Advantage, you pay most costs at the point of service. As a result, inpatient costs can come as quite a surprise. Copays for doctor and specialist visits can add up fast, too.
With Original Medicare and Medicare supplement insurance, you pay most of your costs up-front through monthly premiums. As a result, your medical costs are easier to plan and budget.
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How Much Do Medicare Advantage Plans Cost?
Most people who join a Medicare Advantage plan do so because there is a cost-benefit. The cost-benefit can come from Medicaid benefits, retiree benefits from an employer, or the additional benefits bundled with a plan.
There is a general misconception that Medicare Advantage plans cost less than Original Medicare. This isn't true. In fact, studies show that an inpatient stay in the hospital is likely to cost more with a Medicare Advantage plan, not less.
For this reason, it is very important to do your homework and examine costs when you use healthcare services with a plan. Every plan publishes a summary of benefits document that details all costs. MedicareWire publishes the summary of benefits information on all plan pages. You can download it as a PDF document to easily compare plans.
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When Can I Enroll in a Medicare Advantage Plan?
Unlike Medigap, which does not have a specific enrollment period, you are only allowed to enroll in a Medicare Advantage (MA) plan or Medicare Part D plan (PDP) during the annual election period (AEP) or during your initial enrollment period (IEP). It's critical that you mark these open enrollment period dates on your calendar.
Medicare's annual election period is the same time each year. It starts on 15 October and ends on 7 December. This is an important date to mark on your calendar.
During AEP you can dis-enroll from your existing MA or PDP plan, if you have one, and enroll in a new plan. If this is your first time enrolling, it will be your opportunity to discover the various tools available to compare MA plans.
In addition to AEP, you have your own Initial Enrollment Period (IEP). Your IEP happens once when you first qualify for Medicare benefits. For most of us, our IED happens when we turn 65, but it can also be when you qualify for Medicare due to a disability or ESRD.
Your IEP is a 7 month period that starts 3 months before the month you turn 65, includes the month you turn 65 and ends 3 months after the month you turn 65. In most cases, your Social Security office will send you a reminder.
If you are newly eligible for Medicare because you’re disabled and under 65, you can sign up for a Medicare Advantage Plan or a Medicare Prescription Drug Plan starting 21 months after you get Social Security. Your Medicare coverage begins 24 months after you get Social Security. Your chance to enroll in an MA plan lasts through the 27th after you get Social Security benefits.
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Are Medicare Advantage plans Really an Advantage?
If you've read this far, you might be wondering, is Medicare Advantage worth it? Here's who gets to truly experience the advantage private health plans offer:
- People with retiree benefits that help with Medicare Advantage premiums, deductibles, and copays.
- People who qualify for a Medicare Advantage Special Needs Plan.
- People who are exceptionally healthy and rarely use healthcare services outside of their annual wellness visits.
- People who can't get a Medicare supplement due to one or more chronic health issue who need the maximum out-of-pocket cost safety net built into Part C plans.
If you fall into one of the above categories, then yes, these plans really are an advantage and you should compare plans in your area.
How to Compare Medicare Advantage Plans
One of the minor disadvantages of Medicare Advantage is that plans are difficult to compare and you need to do it every year. The Original Medicare system, with supplemental coverage through standardized Medigap plans, is much easier.
To compare Medicare Advantage plans you need to look at four things:
- Copayments and Coinsurance. Every service has its own costs that the member pays when they use the service. These costs are spelled out in a plan's summary of benefits document. MedicareWire shows the summary of benefits information on plan pages.
- Maximum Out-of-Pocket (MOOP) Cost. This is the maximum you will pay out-of-pocket on copays and coinsurance in a plan year before the plan begins paying 100 percent. It does not include your monthly premiums or prescription drug (Medicare Part D) costs.
- Monthly Premiums. When you join a Medicare Advantage plan you will pay the plan's premium and you must continue to pay your Medicare Part B premiums. Many plans have a zero-dollar premium, which simply means the Part B premium covers the full cost.
- Star Ratings. Each year CMS grades each plan using a 5-star rating system. The star ratings help members understand the quality of care and service they can expect.
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Types of Medicare Advantage Plans
There are several different types of Medicare Advantage plans:
- HMO — Medicare Advantage HMOs provide care through a network of doctors, hospitals, and other medical professionals that you must use to be covered for your care.
- PPO — PPO plans, like HMOs, have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. However, with a Medicare Advantage PPO, you are not restricted to using providers in the network
- HMO-POS — With a Medicare Advantage HMO-POS you have the option to go outside of the network for care, but you'll pay more when you do. Also, The HMO and POS portions of the plan have separate deductibles. Care you receive in-network through the HMO has a different deductible than the care you get out-of-network through the POS.
- COST — Medicare Cost Plans are a type of Medicare health plan available in certain, limited areas of the country. Unlike other plans, you can join even if you only have Part B. If you have Part A and Part B and go to a non-network provider, Original Medicare covers the services. You’ll pay the Part A and Part B coinsurance and deductible. Also, you can get your Medicare drug coverage from either the plan or you can join a Medicare Part D plan.
- PFFS — A Medicare Advantage PFFS plan sounds a lot like Original Medicare and Medigap, but it's not. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care. You can go to any Medicare-approved doctor or hospital that accepts the plan's payment terms and agrees to treat you.
- MSA — Medicare Advantage MSA plans combine a high-deductible insurance plan with a medical savings account that you can use to pay for your health care costs.
- SNP — Special Needs Plans are plans designed to provide healthcare to people with special health and/or financial needs.
Plan Benefits That Go Beyond Original Medicare
From its inception, Original Medicare was designed to cover major medical services. Medicare Advantage plans also cover major medical, but insurance companies are free to bundle extra benefits with their health insurance, as well. The most common benefit included is a prescription drug plan. However, an increasing number of plans also offer routine care for dental, vision, hearing, and more.
Another additional benefit that's quickly becoming a popular option, particularly in the age of the COVID-19 virus, is telehealth. This is a great option for anyone, but it's particularly beneficial if getting to your doctor's office is inconvenient.
Speak with a Licensed Insurance Agent
Ready to enroll? Still have questions? It's time to speak with a licensed insurance agent.
You can enroll through the plan itself, using one of their agents, or use an independent agency like HealthPlanOne, the largest and most trusted Medicare Advantage broker in the country. Your cost will be the same, regardless.
Call 1-855-266-4865 to speak with a licensed advisor.
Frequently Asked Questions About Medicare Advantage Plans
Most Medicare Advantage plans are coordinated care plans, most commonly called HMOs. In this type of plan, your care is coordinated through a primary care physician who acts as a gatekeeper to specialists, lab work, diagnostics, medical supplies, and other healthcare services. Compared to Original Medicare, this is the chief disadvantage. Read about the Top 9 Advantages and Disadvantages of Medicare Advantage Plans.
Medicare Advantage (MA) is a private health insurance option for Medicare beneficiaries. It's one option, but it's not the best option for everyone. MA plans work best for healthy seniors and people who have retiree health benefits, Medicaid benefits, or secondary payor benefits, such as the VA. People with chronic health conditions who do not have retiree health or Medicaid benefit may find a MA plan costs more than Original Medicare. Read the Top 7 Reasons Why Medicare Advantage Plans Are Bad.
Most experts feel that Original Medicare plus a Medigap plan for supplemental coverage is the best coverage you can get. But not everyone can afford a comprehensive Medigap plan. In some areas, most notably Florida, coverage is very expensive, and not everyone will be approved. In these cases, Medicare Advantage is a better option than Original Medicare alone. Read Medicare Advantage vs. Medicare Supplement: Which is Best for You? for more information.
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Citations & References
- Find a Medicare plan
- Medicare.gov: the official U.S. government site for Medicare | Medicare
- Medicare & You: Understanding Your Medicare Choices - YouTube
- How to understand Medicare plans - YouTube
- Medicare & You: Medicare Open Enrollment - YouTube
- Medigap Enrollment and Consumer Protections Vary Across States | KFF
- Medicare Advantage | KFF
- Medicare Advantage 2020 Spotlight: First Look | KFF