When you’re only enrolled in Medicare Part A and Medicare Part B, you get your health benefits through Original Medicare. If you enroll in a Medicare Advantage plan, you’re still enrolled in Original Medicare; however, a private insurance company will deliver your benefits with a Medicare Part C plan. In contrast to Medicare Part A and Part B, the best Medicare Advantage plans are usually HMOs or PPOs and look more like the kind of health plan you may be used to from work or individual health insurance.
Please note that these plans are a little different from Medicare Supplement plans, which are also a popular choice among Medicare beneficiaries. Supplemental plan options work with Medicare Part A and Medicare Part B to fill in gaps in coverage, while Advantage Medicare plans work differently. Many plans through top companies like Cigna, Aetna, Blue Cross Blue Shield, and more also offer extra benefits that you can’t get through a Supplemental plan. For example coverage for dental, health, and vision might be provided, or you may be able to enjoy prescription drug coverage from an included Medicare Part D prescription drug plan.
When Can I apply for a Medicare Advantage Plan?
To qualify for Medicare Part C:
- You must be enrolled in Medicare Part A and Part B.
Otherwise, the government allows people to join a Medicare Advantage plan at these times:
- Initial Coverage Election Period: When you are about to turn 65, you get a seven-month period to enroll in a Medicare Advantage plan. This includes the three months before, the month of, and three months after you are turning 65. People who are disabled and qualify for Medicare Part A and Part B when they are younger than 65, get a somewhat different Initial Coverage Election Period.
- Annual Election Period: This is usually called the AEP, and it occurs for a few months every fall. During this time, you can switch Medicare Advantage plans for coverage that will begin on January 1 of the next year.
- Special Election Period: Several circumstances can trigger a Special Election Period or SEP. These may include moving, losing prior coverage, and other circumstances.
A Medicare beneficiary also has a Dis-enrollment Period every year. During this time, you can choose to drop Medicare Part C, go back to Medicare Part A and Part B, and then join a stand-alone Part D plan if you require drug coverage.
Also, you will use your new Medicare Advantage plan ID card most of the time once your new benefits start. Keep your Original Medicare card in a safe place, but use the new card for services at a doctor, hospital, or another provider.
Comparing Medicare Advantage Plans
This brief list highlights important factors to compare for a Medicare Advantage plan:
- Coinsurance, co-payments, and deductibles
- A network of providers and network rules
- Premiums, benefits, and out-of-pocket costs
- Prescription benefits
Also, Medicare has a system with a star rating for each plan. The star rating gives people a simple way to see how the plan has performed in the past and might perform in the future. A five-star plan is the best, but this is actually fairly rare. If it’s not possible to find a five-star plan, it’s a good idea to do more research into the things other members liked or disliked. This rating system can be quite valuable when you’re shopping for Medicare health plans.
What are the Best Medicare Advantage Plans?
Medicare Part A and Part B work the same way everywhere in the country. A Medicare beneficiary should not assume that each Medicare Advantage plan will work the same way as another one. It’s important to compare different kinds of plans and of course, plans from different insurance companies. The premiums, coinsurance, network, deductibles, copayments, and even the preferences of the beneficiary may impact the best choice for any individual.
It’s helpful to compare the best kinds of MA plans:
Best for lowest cost: Medicare Advantage HMO
Health Maintenance Organization HMO plans: These are most likely to offer modest or even $0 premium rates and affordable out-of-pocket costs. In turn, an HMO will have the most restrictive network rules when it comes to the healthcare providers that you can see. In the US, HMO’s have about 63% of the total market. Monthly premiums are often the most affordable with these plans.
Best for network freedom: Medicare Advantage PPO
Preferred Provider Organization PPO plans: Typically, a PPO may have somewhat higher premiums and out-of-pocket costs. However, they remain popular because they offer the choice to have out-of-network healthcare costs covered when you see a provider outside of the plan’s network. PPOs have about 33% of the market.
Best for chronic health conditions: Medicare Advantage SNPs
Special Needs Plans: Special Needs Plans address the unique needs of people who may have to manage chronic health conditions or institutional conditions.
Best for low income: Medicare Advantage Dual-Eligible:
Medicare beneficiaries may qualify for both Medicaid and Medicare Part A and Part B, and they can enroll in a Dual-Eligible Medicare Advantage plan with a $0 premium and no out-of-pocket costs for covered services.
Are Medicare Advantage Plans Bad?
These are some national enrollment statistics for Medicare Part C:
- Percent of the U.S. market for Medicare insurance: 3%
- Total Number of U.S. Medicare Advantage plan enrollment: 18,973,154
- Most common kind of U.S. Medicare Advantage plan: HMO
As you can see, Medicare Advantage plans are far NOT bad, they are very popular, and cover almost 20 million individuals.
Do Medicare Advantage Plans Cover Prescription Drug Medicine?
Original Medicare only covers prescriptions in limited circumstances, such as inside of hospitals and certain clinics. Medicare Advantage Prescription Drug plans, often called MAPD, do cover prescriptions.
To find the best MAPD, these are some important factors to compare:
- Prescription formulary: This is simply the list of all of the medications covered. Some insurers may make exceptions for unusual circumstances, but these need to be approved in advance.
- Prescription Drug tiers: The insurance company will also classify different prescriptions for different benefit levels, such as for generics, brand names, and specialty medication.
Anybody who relies upon prescription medication should carefully check the formulary and Prescription Drug tiers to find a solution that will pay the highest rates for their own medicine. If prescription needs change, it’s also possible to switch to another Medicare Advantage plan during the Annual Election Period.
Do Medicare Advantage Plans have Network Restrictions?
In the United States, network plans take 96% of all of the enrollment in a Medicare Advantage plan. An HMO will only cover in-network healthcare unless it is an emergency or under other unusual, pre-approved circumstances. A PPO will cover out-of-network providers, but they may charge higher co-payments or deductibles to do so.
In addition, an HMO will require each member to have a primary care doctor. This doctor has to give referrals for visits to specialists and some other medical services. A PPO doesn’t require a PCP or primary care physician. Members of a Medicare Advantage plan are likely to feel satisfied with their coverage if they have a convenient doctor, hospital and other medical services, so it’s important to check the network and to understand it might change each year.
People who move away from their network may get a Special Election Period to switch plans. A few PPOs have national or statewide networks, and these might be convenient choices for people who plan to travel.
Comparing Other Medicare Advantage Plan Benefits
Besides covering prescriptions, a Medicare Advantage plan may offer additional benefits that can’t be found in Original Medicare. For instance, they often help with routine vision and dental and hearing. They may also have wellness programs that include fitness programs or discounts on vitamins and other non-prescription medicine.
Authority Medicare Resources
For some additional help, consider these Medicare resources. They can help you learn more about the options that are available for American Medicare beneficiaries. You may find that these resources will help you answer your questions about things like the Medicare Part B premium or your Medicare coverage, too.
- Medicare’s Medicare Advantage Overview
- The Medicare Extra Help Program
- CMS: Centers for Medicare and Medicaid Services
You can also use our Medicare Advantage quote form to compare your options. This will help you find the best plan for the most affordable price. We’re also here to help you one-on-one, so call and talk to one of our licensed insurance agents today!