Medicare Advantage Plans are insurance plans offered by private insurance companies that take over for Original Medicare Part A and Part B. Medicare Advantage plans usually include your Part D prescription drug coverage, as well as other services such as dental, vision and hearing.
How Medicare Advantage Plans Work
When you are eligible and enrolled into Parts A&B for Original Medicare you have the option to utilize a Medicare Advantage Plan. You will still be responsible for your Part B premiums, but your Advantage plan will take over for Original Medicare, giving you added benefits and coverage.
Instead of being exposed to the Part A deductible and 20% co-insurance from Original Medicare you will have copays, coinsurance and a maximum out of pocket that is set by your Medicare Advantage Plan. This gives you a ceiling for your medical bills and protects you from high yearly costs. If you choose an advantage plan that includes your Part D prescription drug coverage you will also have a deductible and maximum out of pocket for your prescription costs. Every plan will have different costs associated with these so its best to have a local agent assist you in this process.
Choosing a Medicare Advantage Plan
There’s multiple factors that go into choosing the right plan for your needs and budget. The first step is ensuring that your doctors and hospitals are In-Network and accepting that Medicare Advantage Plans. From there we will discuss various coverage options that best fit your specific health needs, such as choosing a plan with better dental or vision benefits, or a plan that has lower copays for specialists. We can shop the plan that will work best for you instead of squeezing you into a “one-size-fits-all” plan. We’ll also verify your medications on the plan’s formulary to know what your medications will cost you throughout the year and ensure the plan will cover them. Don’t miss this steps and have complications, use us as your local agent and we’ll take the headache out of Medicare!
Medicare Advantage Plan Costs
Advantage Plans will typically have a $0/month premium, or very low monthly costs to be enrolled. This is what makes Advantage plans a good fit for a majority of beneficiaries. Advantage plans work as a “pay-as-you-go” system, meaning you will have copayments and coinsurance to utilize your coverage.
Copayments are a set cost that you will pay to see your doctors and specialists, and for some medical services such as X-Rays and MRIs. Most plans have a $0 – $50 fee to see your Primary Care Provider and a $50 -$100 fee to see a specialist, but every plan will have its own specific rates for services.
Coinsurance is a percentage of your hospital or doctor bills that you will be responsible for until you hit your yearly maximum out of pocket (MOOP). The percentage you will be responsible for usually ranges between 20% – 35%, but some plans can go as high as 50%. HMOs usually have lower coinsurance rates compared to PPO plans, but narrower networks that you will have to work with.
Most plans will have a yearly maximum out of pocket ranging from $3000 – $5000, meaning the insurance company picks up the rest of your medical bills after you’ve met this limit. You don’t have to meet your maximum for insurance to cover your primary doctor or specialist visits, as these will have a copay, and that is all you need to pay in order to receive those services. Your MOOP for medical expenses doesn’t count towards your yearly cap for prescription drugs (Part D Prescription Drug Plans).
Medicare Advantage Plan Types
Medicare Advantage Plans are managed care, meaning they will utilize either an HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization), which are networks of doctors and hospitals contracted with the carrier of an Advantage plan. HMOs will have a narrow network compared to a PPO, which typically has more options, but comes with a higher cost for premiums, copayments, coinsurance, and yearly maximum out of pockets.
Under an HMO network you will need a Primary Care Provider that will manage your health care needs. Beneficiaries will need referrals to see their specialists and receive certain medical services. Advantage plans may also require prior authorizations for specific medical services or medications that the insurance company may deem not necessary. Denials can be appealed by your Primary doctor, and alternative options for treatment may be recommended.
PPO networks work similar to HMO networks, but with some key differences. You won’t have to receive referrals under a PPO to see specialists. PPOs tend to have higher costs and yearly out of pocket maximums then an HMO will, but you do have more options and freedom with these networks.
Medicare Advantage Plans can also be offered as a Dual Special Needs Plan (DSNP) which incorporates Medicaid, as well as a Chronic Special Needs Plan (CSNP) that is for beneficiaries with chronic conditions such as diabetes or heart disease.
Dual Special Needs Plans
DSNPs are used for beneficiaries that are on Original Medicare and Medicaid. Medicaid covers various medical services and costs that Original Medicare doesn’t, and a DSNP can add additional coverage such as dental, vision, and hearing.
Chronic Special Needs Plans
CSNPs are used for beneficiaries that have chronic conditions and may offer better benefits compared to a standard Medicare Advantage Plan. CSNPs will often have lower copayments, coinsurance and maximum out of pockets allowing you to save on medical costs. On top of benefits and lower costs a CSNP can also offer access to more specialized care and enhanced coordination for those with qualifying health conditions. You must have qualifying conditions in order to be enrolled into a Chronic Special Needs Plan.
Eligibility Requirements
In order to be eligible for a Medicare Advantage Plan you will need to be enrolled in both parts of Original Medicare, Parts A and Parts B. You will also need to live in the plan’s service area to be enrolled. Advantage plans are not portable, so you will need to make sure your zip code is covered, and if you ever move you may need to change plans. Let me be your local agent and assist you in finding the right plan for you!
Extra Benefits Plans Offers
Medicare Advantage plans typically offer dental, vision and hearing benefits within one plan, making it a one stop shop for all of your health needs. Each plan has its own yearly benefits allowance and differs depending on your financial state and health needs.
Plans will offer coverage for your Part D Prescription Drug coverage (unless using MA only plan) with their own separate copays, coinsurance, deductibles and yearly cap for out of pocket costs.
Plans can also include over the counter benefits and grocery cards. Other benefits include gym memberships, transportation for doctor visits or non medical use, and Part B buy backs. Each plan will have its own benefits with varying limits and perks for each of them.
What You Need to Know Before Enrolling
One of the most important aspects of a Medicare Advantage Plan and knowing if it will work for you is to check if your doctors accept the plan as well as certain specialists or hospitals you may need as well. This is the first step we take with every client to ensure they’re not enrolled into the wrong plan. We also educate you on all of your options, the differences between the plans and networks, as well as checking your prescription drugs on the plan formulary.
Prescription Drug Coverage
Prescription drug coverage is often included in your Medicare Advantage plan (MAPD), offering you coverage for your prescription drugs. Every MAPD plan will have its own premiums, deductible, copays, and yearly maximum out of pocket cost for the Part D prescription drug coverage.
Prior to enrolling into an MAPD plan we will check your prescriptions to see what your expected drug costs will be throughout the year. By doing so we will know what tier your drugs are on, which determines if you will need to meet your deductible and any copayments for your prescriptions.
Over the counter medications are not typically covered under Part D Prescription Drug plans, although some Medicare Advantage plans offer over the counter benefits on a quarterly or monthly basis, that can be used for over the counter medications, vitamins, pain relievers, and first aid supplies.
Medicare Advantage vs. Medicare Supplement
Medicare Advantage Plans have a few key differences from Medicare Supplement (Medigap) Plans. The main difference will be that Medicare Advantage plans are managed care, which means they utilize networks of hospitals and doctors to service their beneficiaries. Medicare Advantage plans are also pay-as-you-go, so you will have lower or $0/month premiums, but you may incur copayments and coinsurance when you use the coverage.
Is Medicare Advantage Right For You?
Medicare Advantage plans include many extra benefits that you would have to purchase separately when using a Medicare Supplement. Among these are Dental, Vision, and Hearing as well as Over the Counter (OTC) benefits, grocery cards, gym memberships and transportation. This can be helpful to enrollees who are on a fixed budget and need as many benefits inside of one plan as possible. This shouldn’t be the only factor for choosing a Medicare Advantage Plan. It’s best to compare the options available in your area and base your decisions on your health needs as well as your budget. Choosing the best plan is case by case, so its best to consult with a Medicare agent, and make an informed decision based on YOUR circumstances only!
Although Medicare Advantage plans have low or $0 premiums, this does not mean that the coverage will be free. As you use your plan you will begin to pay copayments and coinsurance for medical services provided. Depending on your health needs you could reach your yearly maximum out of pocket, which you should evaluate prior to enrolling. In some cases it may be more affordable to use a Medicare Supplement. You may also find that your preferred doctor or hospital only accepts Original Medicare and Medicare Supplement plans. These are all factors that we can help you consider prior to enrolling to avoid mistakes and high out of pocket costs for your health care!
How to Enroll in a Medicare Advantage Plan
When it comes time to enroll into a Medicare Advantage plan we will review the plans available in your specific area to find the best coverage options for your health conditions and budget. From there we will verify that your doctors, specialists and hospitals accept the plan of choice. We’ll also verify your prescription drugs are on the plans formulary and get an estimate for your yearly costs.
We utilize Medicare.gov to compare all of the available plans in your zip code. Once we’ve found a plan that works best for you our licensed agent will enroll you into that plan through the carriers website. The enrollment process can be done in-person at our office or over the phone at your convenience. You can also use the Medicare website or call to find plans and compare, but using an agent is recommended.
Disclaimer: We do not offer every plan available in your area. We represent a number of MA organizations, which offer products in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.
When Should You Enroll?
If you are newly eligible to Medicare due to turning 65 years old, have a qualifying health condition, or being disable for 24 months, you can use your Initial Enrollment Period (IEP) to enroll in a Medicare Advantage Plan. You will need to have Medicare Parts A&B in order to be eligible in a plan. Your initial enrollment period starts 3 months before your 65th birthday and last 3 months after your 65th birthday. It’s important to get enrolled during this period if you qualify in order to avoid late penalties for both Part B and Part D.
You can also utilize the Annual Enrollment Period (AEP) if you are already enrolled into Medicare and using an MAPD or Medicare Supplement plan. This period starts October 15th and ends December 7th. During this period you can switch Medicare Advantage plans or go from a Medicare Supplement plan to a Medicare Advantage plan.
Some individuals will qualify for a Special Enrollment Period (SEP) depending on certain life circumstances such as retirement, moving to a different zip code, losing coverage from your current MAPD plan, or becoming eligible for programs such as Extra Help/Low-Income Subsidy or Medicaid. For those retiring you will have an 8 month window to get enrolled into a plan, but only 63 days to get enrolled in Part D coverage, if its not included in your Medicare Advantage or Supplement plan.
What Happens After You Enroll
After choosing and enrolling into a plan with one of our Medicare agents the carrier will send out your insurance card. Once received you will need to call the number on the back to activate your insurance card. One of our agents can assist you with this if needed!
Coverage will begin the first day of the following month that you enrolled in. If you need a temporary card or confirmation number to utilize before your card comes in the mail on of our agents can assist you!
Why Use an Insurance Agent?
Insurance agent provide you with expert guidance on plans in your area, the best options for you based on your needs, and support with the complications and yearly changes to Medicare at absolutely no cost to you! Medicare can be a confusing topic, which is why we’re here to help you navigate the process. Give us a call today to get free assistance with your Medicare and enrollment needs.