Medicare Advantage Plans

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Upon becoming eligible for Medicare, you are presented with several decisions. One of the initial decisions is selecting the type of coverage that best suits your needs.

Medicare Parts A and B together form Original Medicare. Alternatively, you have the option to opt for Medicare Part C, also known as Medicare Advantage, which is managed by a private health insurance company.

Medicare Advantage plans merge Part A and Part B benefits, and frequently incorporate Part D (prescription drug) benefits. Many beneficiaries opt for the convenience of having all their coverage consolidated into a single comprehensive plan.

To choose an Advantage plan, you need to be enrolled in both Medicare Part A and Part B, and you will still be responsible for paying your Part B premiums. Medicare will then provide a fixed monthly payment to the Advantage plan administrator to oversee your care, and the Advantage plan will cover all your benefits. Furthermore, you must reside within the coverage area specified by the Advantage plan.

The Difference Between Original Medicare and Medicare Advantage

Much of the difference between the two plans involves the way in which you access your benefits.
With Original Medicare, you are subject to deductibles and a 20 percent co-insurance on Part B. You can access care at any doctor’s office or hospital that accepts Medicare (which most do).

Accessing care under a Medicare Advantage plan involves utilizing a network of providers within your coverage region. Co-pays, which differ based on your plan’s structure, are required for various services. Hospital stays may incur a per-day co-pay in some plans, whereas others may charge a fixed amount for the entire stay.

Medicare Advantage plans tend to change more each year, with regard to coverage. However, beneficiaries have the opportunity to review their plans each year, and choose one that best suits their needs for the upcoming coverage year.

The Benefit of Having a Medicare Advantage Plan

Before the inception of Medicare Advantage, individuals under Original Medicare who couldn’t afford a Medigap plan often faced overwhelming medical expenses during critical illnesses or emergencies.

Medicare Advantage plans were designed to offer a safety net for significant medical expenses. These plans feature an out-of-pocket spending limit. Once beneficiaries reach this threshold, the plan steps in to cover medical costs for the remainder of the year (excluding expenses under Plan D, which are handled separately).

Many Advantage plans also include Part D prescription drug coverage, so that beneficiaries don’t have to purchase a separate plan.

How to Choose a Medicare Advantage Plan

Given the multitude of choices available, selecting a Medicare Advantage plan can be a daunting task for most individuals. What suits one person may not be suitable for another, making this decision highly personal. Thankfully, insurance advisors specialize in comprehending the various options and can assist you in finding the plan that aligns best with your requirements.

First, ask yourself some important questions to begin identifying your priorities:
  • Do you have any preferred healthcare providers? Do they accept any Medicare Advantage plans or only Original Medicare?
  • What types of insurance is accepted at your preferred hospital?
  • Are you a frequent traveler out of your coverage area, or do you spend significant time at a second home?
  • How much financial risk can you tolerate? Do you have savings or another source of funding in the event of significant medical bills?
  • How much peace of mind do you want to achieve? Do you need to know that your healthcare spending will remain steady over time? Or are you okay with fluctuating expenses?

HMO vs PPO

By enrolling in an HMO (Health Maintenance Organization) plan, you will need to choose an In-Network Primary Care Physician (PCP). This primary physician is responsible for managing your healthcare and should be consulted first for all non-emergency medical needs. In the event that a specialist is required, your primary physician will direct you to an In-Network specialist.

Health Maintenance Organizations (HMOs) typically offer the lowest premiums, but they come with less flexibility in choosing healthcare providers, and out-of-pocket costs may differ.

With PPO’s or Preferred Provider Organization, you do not have to select a primary care doctor and can “self-refer” to a specialist if you deem it necessary. PPO’s have both In-Network and Out-of-Network options. Although you have the freedom to go directly to any doctor you’d like (provided they accept Medicare), if that doctor is out of the network it will almost always have significantly higher costs associated.

Preferred Provider Organizations (PPOs) provide increased flexibility and out-of-network advantages. On the downside, premiums can be notably higher, making it beneficial to have a broker compare options to find the most cost-effective plan for your situation.

Choosing a Medicare plan requires research, time, and expertise.

There are several factors that will influence your decision. The summaries provided above serve as a brief guide and aim to outline your primary options.

Working with a licensed insurance professional to explore all available options tailored to your needs and budget remains the most effective approach to finding a Medicare plan that fits your requirements.

For additional information, please visit Medicare.gov.

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