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– Medicare Advantage –

What is Medicare Advantage?

Medicare Advantage Plans fall within the Medicare Part C coverage and are an alternative way to receive traditional Medicare benefits.

These plans are Medicare health plans that are offered by private companies who contract with Medicare to provide all or your Part A and Part B benefits, and in some cases your Part D benefits. (Part C = Part A + Part B)

Medicare Advantage plans must provide all the benefits of Part A and Part B, and many plans offer additional coverage too.

Medigap Plans (Medicare Supplement Plans) are not the same as Medicare Advantage Plans. You can not be enrolled in a Medicare Advantage and Medicare Supplement at the same time.

Types of Medicare Advantage Plans

There are several types of Medicare Advantage Plans to choose from, such as:

  • HMO (Health Maintenance Organization)
  • PPO (Preferred Provider Organization)
  • PFFS (Private Fee For Service)

Other types of Medicare Advantage Plans are available for certain individuals that have chronic health conditions and low income. Those plans are:

  • CSNP (Chronic Special Needs Plans)
  • DSNP (Dual Special Needs Plans)

Each plan has different cost and coverage. Some plans (like CSNP and DSNP) plans even offer additional enrollment periods throughout the year.

Chronic Special Needs Plans are designed to provide specific, extra benefits meant for people with certain chronic health conditions. These plans are not available in all areas and not to all beneficiaries.

Dual Eligible Plans are also meant to provide extra benefits and are available for people that have Medicare + Medicaid.

Lets take a look at the Medicare HMO and PPO plans below.

Medicare HMO

  • Generally, you must use plan network of doctors and hospitals within the plan’s service are to receive covered services otherwise the enrollee will out of pocket themselves.
  • Emergency services are considered in-network when traveling outside of the plans service area
  • Maximum out of pocket is generally lower than Medicare PPO plans
  • You may need to select primary care physician and may need referral for specialists.
  • To avoid Part D penalty, you must get a plan with drug coverage as a stand-alone plan cannot be added

Medicare PPO

  • Generally, you can receive care from any doctor that participates in Medicare, but you may pay lower costs if you go to one of the “preferred” doctors in the plan’s network.
  • Typically, there are higher costs for seeking care outside of the “preferred” network
  • Maximum out of pocket costs generally higher than Medicare HMO plans
  • To avoid Part D penalty, you must get a plan with drug coverage as a stand-alone plan cannot be added

  HMO PPO
Costs:  Plans do have maximum-out-of-pocket costs that vary on plan choice and region You pay Medicare premiums, plan premium, copays, and deductibles You pay Medicare premiums, plan premium, copays, and deductibles
Flexibility Low Highest
Networks Network of providers. Network of providers.  National plans cover you in many states.
Out-of-network coverage? Only in an emergency. Covered, plan allows for out-of-network.
Primary care physician required? Yes, in most plans No
Referral necessary for specialist visit? Yes No
Prescription drug coverage? Yes, in many plans Yes, in many plans
Emergency Services Covered Yes Yes
Additional Benefits Yes, in most plans Yes, in most plans

Read more about Medicare HMO vs PPO

Medicare Advantage vs Original Medicare

As you begin your journey and try to decide if you should choose Original Medicare or Medicare Advantage, consider the following:

  • Budget (Premium)
  • Health and Medical Cost (What is you previous and current health? Do you have prescriptions or infusion treatments?)
  • Network (Do you want the freedom to choose any provider you’d like)?
  • Referrals (Consider some plans require referrals for a specialists)
  • Travel (Will you be traveling? How often?)
  • Additional Benefits (Consider what’s important to you. Dental, Vision, Hearing, Prescriptions, etc.)

There are pros and cons to both and depending on your needs, wants and budget will determine while road is better for you. Don’t ever choose an option or plan just because you spouse, neighbor, friend or other relative have it.

Call us at 866-633-4427 and spend a little time with one of our licensed agents and to help determine which is the most suitable option for you.

Medicare Advantage vs Medicare Supplement

Medicare Supplement Plans (Medigap) work with Original Medicare. While Medicare Advantage Plans are private plans that are an alternative way to have Original Medicare benefits covered.

You’ll read and hear how one is better than the other. And, to some debate, that is true. There are pros and cons to Medigap Plans and Medicare Advantage Plans.

You should consider speaking with a licensed agent before enrolling in a plan. Medigap Plans will have a higher monthly premium than Medicare Advantage Plans. And Medicare Advantage Plans may include additional benefits that Original Medicare doesn’t pay for.

On the other hand, Medigap Plans have no network, and you can see any facility nationwide that take Medicare. But, if you have a Medicare Advantage Plan, you will have a network of preferred providers. If you go outside of that network, you will likely incur higher out of pocket costs.

Consider these 3 key differences with Medigap vs Medicare Advantage:

  1. Cost (Premium, Deductible, Copays, Max out of pocket)
  2. Network + Referrals (Freedom to choose)
  3. Additional Benefits (Drugs, Dental, Vision, Hearing, Gym Discounts and much more)!

Medicare Advantage Eligibility

To be eligible to enroll in a Medicare Advantage Plan, you will need to be eligible for or enrolled in Medicare Part A and Part B.

Although Medicare Advantage is considered a “replacement plan” to Medicare, that’s just not true. You still need to have Part A and Part B to enroll in a Medicare Advantage Plan.

Medicare Advantage Initial Enrollment Period

Your first opportunity to enroll in a Medicare Advantage Plan will be when you are first eligible for Medicare (under 65 due to disability) or, when you turn 65. This is also referred to as your Medicare Initial Enrollment Period.

This period lasts for 7 months, which begins 3 months before your Part B effective date, month of and 3 months after.

Medicare Advantage Annual Enrollment Period

Aside from when you are first eligible for Medicare or turning 65, the Annual Enrollment Period is the time change or enroll into a Medicare Advantage Plan and/or a Prescription drug plan.

The Annual Enrollment Period runs each year from October 15th – December 7th.

If you are eligible for Medicare and regardless of the plan you have, you can make plan changes.

Medicare Advantage Open Enrollment Period

Another enrollment period specific to Medicare Advantage Plans is the MAOEP (Medicare Advantage Open Enrollment Period). The MAOEP runs every year form January 1 – March 31.

To be eligible to make plan changes during the MAOEP, you MUST have a Medicare Advantage Plan.

If you have a Medicare Advantage Plan, then you can do one of the following:

  1. Replace your current Medicare Advantage Plan with another one
  2. Cancel your current Medicare Advantage Plan and go back to Original Medicare Only

If you go back to Original Medicare only, it is highly encouraged you enroll into a Medicare Supplement and stand-alone Medicare Drug Plan.

Summary of Medicare Advantage Program

  • Must have Part A and Part B to enroll
  • Part C = Medicare Advantage (Part A+ Part B and sometimes Part D)
  • Sometime referred to as Medicare Replacement Plans (although you never technically get rid of Medicare)
  • May include additional benefits that Original Medicare doesn’t not offer
  • Enroll or change plans during the Annual Enrollment Period (October 15-December 7th)
  • May also be eligible to make change during the MAOEP (Medicare Advantage Open Enrollment Period), which runs from January 1-March 31.

Need Help Finding the Best Medicare Advantage Plan?
Our licensed advisors are here to help you select the right options for your needs, budget, and lifestyle. Together we’ll come up with a plan that suits you. Call one of our licensed advisers now by dialing 1-866-MEDIGAP (633-4427). You can also CLICK HERE to schedule an appointment with one of our specialists.

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– Medicare Advantage –

 Medicare Advantage Questions & Answers