Medicare Advantage (MA) plans are a choice for people approaching or in retirement who are already enrolled in Medicare Part A or B or have an Original Medicare plan. If you want more from your Medicare plan, you may want to join an Advantage plan.
What Is Medicare Advantage?
MA plans, also called Part C, are from private companies approved by Medicare and must follow all Medicare rules. In addition, these plans may provide prescription drug insurance, which is Part D.
Since these are private plans, you'll often need to use facilities and doctors that are in-network.
Plans have limits on annual out-of-pocket costs, and you may be able to go outside of a network for a higher price. Your plan may require you to have a primary care provider and a referral if you need to see a specialist.
Medicare Advantage plans fill in the gaps most enrollees have under Original Medicare to offer a more robust form of healthcare.
Who Should Join a Medicare Advantage Plan?
Medicare can help you protect your financial well-being and health. MA plans are a good option for any enrollee who wants to manage their coverage under one approved plan. These plans offer you the additional coverage many enrollees feel is lacking from Part A and B, including:
· Additional coverage for medical and hospital benefits
· Prescription coverage (in many cases)
· Wellness programs
· Orthopedic plans
For many Medicare enrollees, it makes sense to join an MA plan because it offers the option to manage your health with greater coverage options. Medicare advantage plan enrollees tend to save money on their premiums compared to Medicare Supplements.
Average premiums in 2021 are $21 but range from $0 to $100+.
What to Look for When Choosing a Medicare Advantage Plan
As Medicare premiums rise, a Medicare Advantage plan can seem like an attractive option. But if you are considering switching from traditional Medicare to a Medicare Advantage plan, you need to know what to look for.
Medicare Advantage plans are run by private insurers, unlike traditional Medicare, which the federal government operates, although the medical providers are private. The government pays Medicare Advantage plans a fixed monthly fee to provide services to each Medicare beneficiary under their care. The less money they spend on patient care, the more money they and their investors make. The plans often look attractive because they offer the same basic coverage as traditional Medicare plus some additional benefits and services that traditional Medicare doesn't offer at a seemingly lower cost. However, if you get sick and need specialized treatment, the costs could quickly add up.
To compare Advantage plans, go to the Medicare Plan Finder at Medicare.gov. When deciding whether a Medicare Advantage plan is right for you, the following are the main factors to consider:
Cost. Since Medicare Advantage plans are offered by private insurers, the cost of the plan varies depending on where you live. While Medicare Advantage plans usually have lower premiums than paying for traditional Medicare plus a Medigap plan, they can have higher deductibles and co-pays, especially for expensive care like cancer treatment. You need to take these out-of-pocket costs into account. Medicare Advantage plans do have a cap on out-of-pocket costs, while traditional Medicare does not, but that cap can be quite high. Check the annual maximum out-of-pocket costs for the plan. If you have a high level of health costs, a low out-of-pocket maximum may be the best option.
Coverage. What coverage does the plan offer? Medicare Advantage plans must cover everything that traditional Medicare covers, but some plans offer additional benefits, such as dental, hearing, and vision. Plans may require your doctor to get approval for certain procedures. If the plan administrators disagree with your physician that a procedure is medically necessary, the plan may refuse to pay for it. You will want to find out how the plan is about approving treatments, referring patients to specialists or allowing patients to remain in the hospital if they are not ready to leave. You may want to check with your doctors to find out their experience with the plan and whether the plan frequently overrules the doctor.
Doctors and other providers. Traditional Medicare does not have any restrictions on which provider you use (as long as the provider accepts Medicare), but Medicare Advantage plans are HMOs and PPOs, meaning that not every doctor who accepts Medicare will accept the plan’s insurance. With an HMO, if you visit a doctor outside of the network, you will likely have to pay out of pocket (except in an emergency). With a PPO, you can usually see any doctor you want, but you will pay less for an in-network doctor. You will want to check if your doctor and hospital are part of the plan’s network. The best way to do this is to call your doctor’s office to confirm.
Prescription drugs. Most Medicare Advantage plans include prescription drug coverage, so you should check to make sure the plan covers all the medications you take. You should also check if you need any special authorizations for any of your medications or if there any limits on the amount you can get. Other questions include whether your pharmacy is a preferred provider and whether you can get prescriptions by mail.
Quality of care. The Medicare Plan Finder includes a rating system that measures how well the plan manages health screenings and chronic conditions as well as how many customer complaints it receives, among other things. The ratings aren’t perfect, but they can give you an idea of plan’s quality.
Types of Medicare Advantage Plans
Health Maintenance Organization (HMO) plans require you to use in-network:
- Medical facilities
If you need to go to an emergency room or need urgent care, you can go out of network. When seeing a specialist, you'll need a referral from your physician. Prescriptions are likely covered, but coverage depends on the plan.
Preferred Provider Organization (PPO) plans are similar to HMOs in that you'll need to use a preferred network if you want to pay less for your doctor visits or prescriptions. However, you can go to a doctor out of your network, but you'll likely pay more.
If you need to go to a specialist, you won't need a referral.
Your prescription drugs will be covered in most cases.
Private Fee for Service (PFFS) plans are an attractive option because you may or may not have to use a provider network, depending on the plan. Providers outside of a network have a right to accept or deny coverage for any patient and service required.
Specialists don't need a referral, and prescriptions may or may not be covered under the PFFS plan.
Special Needs Plans | D-SNP
If you have special needs, and you are eligible for both Medicare and Medicaid you may be eligible for a Dual Eligible Special Needs Plan (D-SNP). These plans offer many benefits, including prescription drug coverage and often financial assistance (e.g. allowance of funds to put toward utility bills and/or healthy foods, etc...). You'll often need a primary care doctor. Special needs plans require you to meet certain requirements, such as:
- Limited income / eligible for Medicaid.
- Specific disease
- Certain healthcare needs
Eligibility will be the primary concern when applying for special needs plans. But, if you're eligible, these plans are a great option with superb coverage. If you are not eligible, an elder care attorney, can help legally and ethically obtain Medicaid eligibility.
Are You Eligible to Enroll?
Medicare Part C is available to anyone who is enrolled in Medicare. Approximately 23.4 million out of 37 million enrollees are utilizing the benefit of MA plans. Your plan eligibility will depend on:
- Citizenship or lawful status
- Location/service area
You'll need to apply during enrollment periods if you want to join, drop or switch Medicare Advantage plans. There are three main enrollment periods when you'll have the opportunity to join an MA plan:
- Initial enrollment: When you're initially eligible for enrollment in Medicare, you'll have the option to enroll in one of the many Advantage plans in your area.
- Open enrollment: A period that runs from October 15 to December 7 annually. You can join, drop or switch plans during open enrollment.
- General enrollment: After your initial enrollment period, you can sign up for Medicare under general enrollment. This period runs from January 1 to March 31 annually. During this period, you can enroll in Medicare Part A and B. Then, you can apply for an advantage plan between April and June.
If you miss the enrollment period, you'll need to wait until open or general enrollment is available again to apply.
Get Started With Your Medicare Advantage Plan Today
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