Almost half of the 28 million eligible Medicare population are enrolled in a Medicare Advantage Plan, and enrollment has grown steadily since 2006. The Open Enrollment period allows beneficiaries to review changes to their current plan and elect to enroll in a different one. Still, according to the Kaiser Family Foundation (KFF), 71% of beneficiaries did not compare their current Medicare plan to any other plans for the upcoming coverage period.

Changes to plans can occur each year, which could result in unanticipated health care costs and interruptions in care for beneficiaries who don’t annually review their coverage and weight their options during the Open Enrollment Period. So it is crucial for beneficiaries to properly review their current coverage, research what options are available and enroll in the plan that best fits their needs.

It’s totally up to you to figure out what you value most in your Medicare Advantage plan. Lining them up side-by-side can really help clear things up. You’ll want to look at the additional perks, availability of Medicare Part D plan (drug coverage), the costs (premium, deductibles, copayments/coinsurance), maximum out-of-pocket costs, the care you’ll get, and how good the plan is overall. It’s like shopping for the perfect fit — you’ll know it when you see it.

Why you should shop around before you enroll

Even though Medicare Advantage plans are offered through private companies, each plan is required to follow Medicare rules and cover the same services that Original Medicare (Part A and Part B) covers. Where they differ from Original Medicare is in the flexibility they offer. MA Plans go above and beyond what’s required and provide different levels of coverage and types of care, along with different price tags.  

Many MA Plans also offer add-on insurance, benefits, and perks. Most plans offer additional coverage for services left out of Original Medicare, like dental, hearing, and vision care. They also often include nice-to-have benefits like gym memberships, over-the-counter medication discounts, or transportation to doctor appointments. By comparing plans, you ensure you find the one that fits in perfectly with your health needs and budget.

Medicare Advantage plans have many benefits. They:

• May save you money;
• Limit your out-of-pocket costs;
• Can allow you access to your preferred doctors and hospitals (you need to check if your preferred doctors are in the plan’s network);
• Offer you additional coverage not included with Original Medicare;
• Provide nice-to-have incentives like gym memberships;
• Provide the convenience of having one plan for all your needs.

Medicare plans and availability vary by state and county, and here is where it can get confusing. On average, a Medicare beneficiary has 43 Medicare Advantage plans available to them. In some counties, that number climbs as high as 87. 

With so many options available, finding the right plan seems overwhelming.    

So how do you choose?

Medicare Advantage Plan Types

Preferred Provider Organization (PPO):

• More flexibility in choosing providers; out-of-network care is covered but at a higher cost.
• Wider network; no referrals needed for specialists.
• Higher premiums; costs more for out-of-network care.

Health Maintenance Organization (HMO):

• Requires choosing doctors within the network; referrals needed for specialists.
• Lower premiums and out-of-pocket costs.
• Limited provider choice; out-of-network usually not covered.

Special Needs Plans (SNP):

• Tailored for specific groups with chronic conditions or special health care needs.
• Specialized care for specific conditions.
• Must qualify for the special group serviced.

Private Fee-for-Service (PFFS):

• You can see any doctor who agrees to the plan’s payment terms.
• Flexibility in choosing providers.
• Costs can be unpredictable; not all providers accept PFFS terms.

HMO Point-of-Service (HMO-POS):

• A variant of HMO plan that may allow some out-of-network care at a higher cost.
• More flexibility than standard HMO.
• Higher out-of-network costs; may still need referrals.

Medicare Medical Savings Account (MSA):

• Combines a high deductible health plan with a bank account to use for medical expenses.
• Savings account to pay for medical costs.
• High deductible; no drug coverage.

What to look for when comparing Medicare Advantage plans?

There’s no one-size-fits-all when it comes to comparing Medicare Advantage plans. Your health insurance needs are unique like your healthcare needs.

Plans

Begin by accessing the list of providers and plans available to you

At their most basic, all Medicare Advantage plans cover Part A and Part B, but the insurance providers, benefits, and costs will vary from plan to plan.

When you compare Medicare plans online or through an agent, you’ll be asked to provide your zip code to determine which plans you can choose from. Your list of plans may be very different from someone who lives in another state as some plans are only available in a certain state, city, or even a single ZIP code.

Here’s a quick lowdown of the things you need to consider when browsing plans:

• Identify Your Healthcare Requirements: List your frequent medical services, preferred doctors, and any regular medications.
• In-Network vs. Out-of-Network Care: Understand the cost implications of using out-of-network providers and whether out-of-network care is covered.
• Referral Policies: Find out if you need referrals to see specialists and how easy it is to get those referrals.
• Travel Coverage: If you travel often, check if the plan provides coverage in other areas or states.

Decide if you need prescription drug coverage 

In most cases, you can’t enroll in a standalone Medicare Part D plan (drug coverage) with a Medicare Advantage plan. You should exclude plans without Part D from your search if you need drug coverage.

You can only join a separate prescription drug coverage plan (Part D) with certain types of plans that:

• Don’t offer drug coverage (like Medicare Medical Savings Account plans)
• Choose not to offer drug coverage (like some Private Fee-for-Service plans) 

Determine if you’re eligible for a SNP plan

An SNP is a Medicare Advantage plan available in particular situations. If you qualify, an SNP typically provides better coverage for your situation. There are three types: 

• Dual Eligible SNP – If you’re enrolled in both Medicare and Medicaid. 
• Institutional SNP – For beneficiaries living in an institution or requiring an institutional level of care at home. 
• Chronic Condition SNP – For those with certain disabling chronic conditions.  

Checking your SNP eligibility:

• Your Health Status: Dealing with serious, long-term health issues? There could be a C-SNP with your name on it.
• Your Living Situation: Spending your days in a long-term care facility? An I-SNP could make your life easier.
• Your Coverage: If you’re covered by both Medicare and Medicaid, a D-SNP can help streamline your healthcare.

Cost

There’s more to the cost of an insurance plan than the monthly premium. Keep in mind you’ll also have to pay out-of-pocket costs that might include a deductible, copay, and coinsurance. Before you begin a Medicare Advantage plan comparison, take some time to estimate your medical needs for the upcoming year.

• Premiums: Determine whether the monthly premium aligns with your budget and if it makes sense for your anticipated healthcare usage.
• Deductibles and Co-Pays: Evaluate how often you’ll be paying co-pays and if there’s a deductible you must meet before the plan begins to pay.
• Maximum Out-of-Pocket Limit: Consider plans with lower maximum out-of-pocket limits if you anticipate high medical expenses.
• Part D Costs: For plans including prescription drug coverage, consider the cost of drugs under the plan, including the deductible and co-payments for your specific medications.

The average premium in 2023 is $17.86 per month and is projected to rise to $18.50 per month in 2024. Just a heads-up, the overall cost can swing pretty wildly based on the type of plan you pick, what co-pays look like, whether or not your prescription drugs are covered, and any extra perks.

The costs for Medicare Advantage PPO and Medicare Advantage HMO plans for 2023 are:

PPO:

• MA-PD premium /month in 2023: $17 per month for local PPOs and $46 per month for regional PPOs
• Average out-of-pocket (in-network): Local PPOs: $5,561, Regional PPOs: $6,842
• Average out-of-pocket (out-of-network): Local PPOs: $3,044, Regional PPOs: $2,801

HMO:

• MA-PD premium /month in 2023: $14
• Average out-of-pocket (in-network): $4,033
• Average out-of-pocket (out-of-network): Paid 100% by the enrollees

If you don’t usually need much care and don’t normally have drug costs, a low monthly premium could be your most cost-effective choice. If you expect to have frequent treatment, expensive procedures, and numerous prescriptions, then a higher monthly premium with lower out-of-pocket costs may be your best choice.

Care

Insurance providers save money by contracting with provider networks. The cost savings are passed down to you when you get your care at the contracted networks. Some plans like Medicare Advantage PPO allow you to go outside the network, but you’ll pay higher copays and coinsurance. On the contrary, Medicare Advantage HMO does not offer out-of-network coverage, except in emergencies, urgent care, or out-of-area dialysis.

Before deciding, check if your healthcare providers are covered under each plan. Or, if they’re not, ask yourself if you’re comfortable going to different healthcare facilities and seeing different providers than you’re used to.     

Extras

These benefits and perks can add up to big savings while offering you much more than a basic plan.

• Vision, Dental, and Hearing: Compare the extent of the coverage for routine services and corrective devices.
• Wellness Programs: Assess the value of wellness benefits such as fitness programs, weight loss programs, or smoking cessation support.
• Over-the-Counter Allowances: Some plans offer allowances for over-the-counter medications and health-related items, which can be beneficial for routine health management.

Quality

Finding a plan with the right benefits, cost, and extras only tells you what coverage you’re buying. It can’t tell you how well the plan is managed, how happy customers are with it, or how the insurance provider treats their clients. 

To help you make the best decision possible about your health plan, the Centers for Medicare & Medicaid Services (CMS) rate the quality of Medicare health and drug plans annually based on up to 38 quality and performance measures. Each plan’s Star Rating is published with the upcoming year’s plan information so you can see at a glance if a plan is meeting expectations.  

Here’s a summary of how you should gauge Medicare Advantage plans:

• Star Ratings: Medicare Advantage plans are rated on a scale from one to five stars, with five being the highest. Consider plans with higher ratings for better quality assurance.
• Customer Reviews: Look for reviews and testimonials from current members about their experiences with the plan’s customer service and care coordination.
• Plan Performance History: Research any news or reports on the plan’s historical performance, including any sanctions or penalties by regulatory agencies.

Choosing a Medicare Advantage plan: a step-by-step comparison guide

1. Identify Your Healthcare Requirements: List your frequent medical services, preferred doctors, and any regular medications.
2. Access Plan Options: Use the Medicare Plan Finder on Medicare.gov or consult a licensed insurance agent for a comprehensive list of available Medicare Advantage plans in your area.
3. Check Provider Networks: Ensure your preferred doctors, specialists, and hospitals are in-network. If you’re willing to change providers, assess the quality and accessibility of those within the plan’s network.
4. Prescription Drug Coverage (Part D): If you require regular medications, ensure that the plan covers your prescriptions at a cost-effective rate. Check the formulary for drug tiers and associated co-pays.
5. Compare Out-of-Pocket Costs: Look beyond the monthly premium. Calculate the annual costs considering the deductible, co-pays, and coinsurance. Use the plan’s summary of benefits to understand the maximum out-of-pocket costs.
6. Extra Benefits and Services: Consider the value of additional benefits like dental, vision, and hearing coverage, wellness programs, and gym memberships.
7. Quality of Care: Research plan ratings through the CMS star rating system, considering customer satisfaction and performance.
8. Utilize Comparison Tools: Employ available tools like the Hella Health Online Personal Shopper for personalized plan recommendations.

Move into 2024 knowing your health is covered

Choosing the best healthcare insurance for your needs and budget can be overwhelming. Choosing wrong can mean you end up overpaying all year to be over-insured or finding yourself under-insured when you need help.

Fortunately, technology today makes it easier than ever to make the right choice. You can research your health conditions online and estimate your healthcare needs, compare MA plans online, and even enroll online.  

Hella Health brings personal shopping to health insurance

You don’t have to be an expert on health insurance. We created the Hella Health Online Personal Shopper to help you get personalized recommendations about Medicare plans. Just enter your zip code to get started, and we’ll walk you through your Medicare Part C plan comparison based on your available plans.

Article updated on November 29, 2023