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Although Medicare Advantage plans are required to offer certain basic minimum coverages, plan features, costs, and additional coverages can vary depending on the provider. However, regardless of the provider, Medicare Advantage plans will include your Medicare Part A and Part B benefits as well as prescription drug coverage (Part D).
How does a Medicare Advantage plan work?
A Medicare Advantage plan offers all the benefits found in Original Medicare, including coverage for hospitalization (Part A) and medical expenses (Part B). In addition, Medicare Advantage plans also include prescription drug coverage and, in most cases, coverage for hearing, dental and vision care.
If you have a Medicare Advantage plan, your provider will set the rules, including the network of providers you can use and whether you need a referral to see a specialist. Premiums can also vary depending on the provider you choose, so it is important to compare Medicare Advantage plans to find the most affordable options in your location.
Eligibility for Medicare Advantage
Anyone who is eligible for Original Medicare (Medicare Part A and Part B) and has enrolled in it, can apply for a Medicare Advantage plan.
You also need to live in a location where the Medicare Advantage plan that you want is available. Some Medicare Advantage plans may not be available in all locations, so it is important to verify availability in your location when looking for a suitable plan.
What does Medicare Advantage cover?
Medicare Advantage plans or Part C plans are quite popular since they offer better coverage compared to Original Medicare. Some of the coverages included in Medicare Advantage plans include:
Hospitalization insurance
Similar to Medicare Part A, Medicare Advantage plans will cover the cost of hospitalization, including:
· Inpatient hospital care;
· Care at a skilled nursing facility;
· Hospice care;
· Some home health services;
Medical Insurance
Medicare Advantage also includes medical insurance similar to Part B coverage in Original Medicare. This coverage will cover the cost of:
· Doctor visits or outpatient care;
· Preventive services like cancer screening or approved vaccinations;
· Durable medical equipment like wheelchairs, crutches, and other required medical devices;
· Mental healthcare;
· Some prescription drugs;
Prescription drug coverage
Most Medicare Advantage plans include this prescription drug coverage. This covers the cost of specified prescription drugs. You can find out the list of drugs that are covered by your Medicare Advantage plan from your preferred provider before signing up for a plan.
Dental, vision, and hearing coverage
Most Medicare Advantage plans will include coverage for dental, vision, and hearing health care. However, since coverage benefits can vary from provider to provider, always check with your preferred provider if these services are covered and the applicable terms and limits.
Extra benefits coverage
The number of Medicare Advantage plans has been growing steadily for the past decade, which has encouraged private insurance carriers to come up with extra benefits besides dental, vision, and hearing coverage. Medicare Advantage plans may offer eyeglasses, fitness benefits, over-the-counter benefits, meal benefits, transportation benefits, acupuncture, in-home support services, bathroom safety devices, and telemonitoring services, among others. Depending on your needs, some benefits may be more relevant than others. Remember to always check with your plan to understand what is covered.
How much do Medicare Advantage plans cost?
Since Medicare Advantage plans are offered by private insurance companies, premiums and costs may vary depending on your provider. However, you can expect to incur the following costs if you enroll in a Medicare Advantage plan.
· Part B premium: Since Medicare Advantage plans include Part B coverage, you will be required to pay the applicable part B premium. Part B premium is $174.70 per month in 2024.
· Coinsurance and copayments: Medicare Advantage plans incur coinsurance and copayment costs that will be set by the specific plan provider that you choose. Unlike Original Medicare, people on Medicare Advantage cannot purchase a Medigap plan to cover the cost of deductibles or copayments. But unlike Medicare Original, Medicare Advantage plans usually offer a maximum-out-of-pocket which limits the expenses you may face.
· Medicare Advantage premiums. Apart from the Part B premium, your Medicare Advantage plan may charge a separate monthly premium. This premium will be set by the plan provider and may depend on the range of coverages offered, your location, and other factors.
Types of Medicare Advantage plans
There are different types of Medicare Advantage plans, including:
· Health Maintenance Organization (HMO) Plans: This type of plan has a specified network of health care providers that you are required to use if you want your plan to cover the costs. If you use providers outside of your HMO’s specified network, you will have to pay the costs out of pocket.
· Preferred Provider Organization (PPO): This type of Medicare Advantage plan has a preferred network of providers that you can use. However, unlike HMOs, PPO plans offer flexibility where you can use in-network and out-of-network providers, but you will pay less if you use in-network providers.
· Special Needs Plan (SNP): this type of Medicare Advantage plan caters to people who have chronic illnesses and those who qualify for both Medicaid and Medicare.
· Private Fee-For-Service (PFFS): these types of plans are not common. They typically do not include coverage for prescription drugs and are not necessarily network-based. However, providers that are not on the network need to accept Medicare reimbursement and terms set by the Medicare Advantage plan.
When should you choose Medicare Advantage?
If you are not sure whether you need a Medicare Advantage plan, here are some instances when a Medicare Advantage plan may be a better option compared to Original Medicare.
· If you want a plan that offers prescription drug coverage;
· If you want a plan that offers dental, vision, and hearing coverage;
· If you want to have a limit on out-of-pocket costs;
Cons of Medicare Advantage plans
Although Medicare Advantage plans may offer more comprehensive coverage compared to Original Medicare, these plan types also have drawbacks that you should be aware of. These include:
· Limited to provider networks that may narrow your options of preferred health care providers;
· No option to buy a Medigap policy to cover coinsurance and deductibles;
· A referral from your primary physician is needed to see specialists;
Enrolling in Medicare Advantage
If you would like to enroll for a Medicare Advantage for the first time, switch from Original Medicare to Medicare Advantage or switch from one Medicare Advantage plan to another, you can do it during the following enrollment periods.
· Initial enrollment period: you can enroll for Medicare Advantage when you first become eligible for Medicare. This initial enrollment period is a 7-month time frame starting three months before your 65th birthday month and running up to three months after your birthday month.
· Medicare open enrollment period: During the yearly Medicare open enrollment from October 15 to December 7 you have the option to switch from Original Medicare to Medicare Advantage. You can also switch from one Medicare Advantage plan to another.
· Medicare Advantage open enrollment: the Medicare Advantage open enrollment runs from January 1st to March 31st. During this period, you can switch from one Medicare plan to another. However, you cannot enroll for Medicare Advantage from an Original Medicare plan during this period.
· Special enrollment period: in some circumstances, you may qualify for special enrollment. This type of enrollment allows you to enroll in Medicare Advantage outside of the set yearly enrollment periods.
