What is Medicare Advantage
Medicare Advantage is also sometimes referred to as Medicare Part C, and refers to private insurance companies that provide your Original Medicare (Part A and B) benefits. Each of the companies offering Medicare Advantage plans is approved by Medicare, and when you receive covered services, Medicare pays the private insurer. Each Medicare Advantage plan is different, and can include additional coverage above Original Medicare, but it must provide at least the same level of coverage as Original Medicare. The one exception to this is hospice care, which will continue to be covered by Medicare.
Types of Medicare Advantage Plans
In many cases the most common types of Medicare Advantage Plans are similar to those you would have been a member of prior to becoming eligible for Medicare with some other less common plans. These plans include, Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO’s), Private Fee-for-Service (PFFS), Special Needs Plans (SNPs), HMO Point-of-Service (HMO POS), and Medical Savings Account (MSA).
Health Maintenance Organization – In a HMO, you are typically required to go to certain doctors within a specific network. While this limits the selection of doctors you have, it typically results in lower costs. If this is acceptable, then you typically select a primary physician within the network, and often need referrals from that physician to see other specialists.
Preferred Provider Organization – These plans typically give you more flexibility in the doctors you see, but with higher premiums. Most PPO’s have a network of doctors for which you will receive the most beneficial pricing, but you are able to use out-of-network doctors an still be covered, but you may pay more. The other benefit of a PPO is the ability to go see specialists, and other doctors without the referral of a primary physician.
Private Fee-for-Service – These plans typically do not require primary physicians or referrals. You have more flexibility with this plan assuming the physician you want accepts the plan, but be aware that not all doctors do accept these plans.
Special Needs Plan – These plans are built for people with special needs as the name implies. Some of those situation might include people living in a nursing home, those who are on both Medicare and Medicaid, and people with certain chronic conditions. You can find more information on how to qualify for a Special Needs Plan at
Medicare.gov.
HMO Point-of-Service – These HMO plans can operate more similarly to a PPO in that you can sometimes get services from out-of-network physicians. As with a PPO, this most likely means you will pay a higher cost for the service.
Medical Savings Account – With an MSA you combine a bank account with a high-deductible health plan. Medicare then deposits money in the account to use towards health services. Often the amount Medicare deposits is less than the deductible, so if you end up using a large amount of services in a given year, it could cost you more out-of-pocket dollars.
Who Can Join a Medicare Advantage Plan?
Getting a Medicare Advantage Plan is fairly straight forward assuming you meet some basic criteria:
- You must live in a the service area of a Medicare Advantage Plan that fits your needs. Call individual plans to get more detail on their services areas and coverage.
- You must have Medicare Part A and B.
- You don’t have End-Stage Renal Disease (ESRD)
What do Medicare Advantage Plans Cover?
At their most basic, Medicare Advantage Plans are required to at a minimum give the same coverage as Original Medicare accept hospice care. Hospice care continues to be covered by Original Medicare. From there some plans will offer more services above and beyond Original Medicare such as vision, dental, and hearing services, with some even offering wellness programs. Another important thing to remember is the Original Medicare does not come with prescription drug coverage. Many Medicare Advantage Plans do offer prescription drug coverage so that you can receive all of your benefits from the same place. Be sure as you search for right plan that they cover the drugs you need.
