Medicare Advantage Basics

Medicare Advantage, also called Part C, is a Medicare health plan offered by private companies. These plans are considered an alternative to Medicare and cover all the same services covered by Original Medicare. These plans may also offer additional benefits that Original Medicare doesn’t offer. There are two primary options for Medicare beneficiaries: 

• • Medicare Parts A & B, also called Original Medicare. This can be supplemented with a Medicare Supplement, also called “Medigap” to help pay for out-of-pocket costs associated with Original Medicare.
  • Medicare Advantage is considered an all-in-one health care solution, meaning it replaces Original Medicare, and does not need to be supplemented with anything. In fact, you cannot have a Medicare Advantage plan and a Medicare Supplement plan at the same time.

There are many benefits to Medicare Advantage. It offers the convenience of having all of your health and drug benefits under a single plan, instead of enrolling in a separate, stand-alone Medicare Prescription Drug Plan (for Medicare Part D coverage). Some Medicare Advantage plans also offer extra benefits that Original Medicare doesn’t cover, such as routine vision and dental coverage.

What is a Medicare Advantage plan?

Medicare Advantage plans are full-replacement alternatives to Original Medicare, Parts A and B. Instead of having Medicare benefits administered through the federal program, beneficiaries can instead opt to get their coverage through a Medicare Advantage plan. These plans are administered through private insurance companies that contract with Medicare.

All Medicare Advantage plans are legally bound to provide at least the same level of coverage as Original Medicare, Part A and Part B. (The one exception to this is for hospice care, which Part A still covers.) The benefits are not just limited to that, however—some plans may also contain additional benefit coverage, such as prescription drugs, routine vision and dental, hearing, or health wellness programs.

If you would like to take advantage of prescription drug benefits, known as Medicare Part D, you don’t need to enroll in a separate Medicare Prescription Drug Plan. Rather, this is a benefit commonly available through a Medicare Advantage Prescription Drug plan. It’s worth noting that not every Medicare Advantage plan includes prescription drug coverage, so be sure to double-check with the plan details.

Common Medicare Advantage Plan Types

Medicare Advantage comes in a variety of plan options. It’s best to compare the different Medicare Advantage plan options for your state. Some of the most common options available in many locations include:

• • Preferred Provider Organization (PPO) plans – this is a type of Medicare Advantage Plan offered by a private insurance company. PPO Plans include network doctors, health care providers, and hospitals. In most cases, you do not need a referral to see a specialist. You will usually pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s Network than those outside of Network.
  • Health Maintenance Organization (HMO) plans – this is a type of Medicare Advantage Plan that normally requires you to seek health care coverage from doctors, specialists, or hospitals in the plan’s network, except in an emergency or urgent care situation.
  • Special Needs Plans (SNPs) – this is a type of Medicare Advantage Plan, just like the HMO or PPO plans above. Medicare SNPs typically limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best accommodate the specific needs of the groups they serve.
  • Medicare Medical Savings Account (MSA) plans – A Medicare Medical Savings Account (MSA) plan is a plan that combines a high-deductible health plan with a medical savings account.
  • Private Fee-for-Service (PFFS) plans – this is a type of plan offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Medicare Advantage Eligibility

Once you are enrolled in Original Medicare Parts A and B, you’ll become eligible to enroll in a Medicare Part C (Medicare Advantage) plan. As long as you reside within the market service area of the Medicare Advantage plan you choose, and you don’t have end-stage renal disease (ESRD), you will be eligible to enroll. In some cases, even if you do have ESRD, it may be possible to enroll in Medicare Advantage.

There are specific windows that you are able to enroll in a Medicare Advantage Plan including:

• • Initial Enrollment Period – When you first enroll in Medicare there is an Initial Enrollment Period, during which you can choose to add a Medicare Advantage plan.

• • Annual Open Enrollment Period – Each year, there is an Annual Open Enrollment period from Oct. 15 through Dec. 7. During this time, you may enroll in a new or different Medicare Advantage plan or Prescription Drug Plan.

• • Special Enrollment Period – Sometimes, due to special situations, people qualify for a Special Enrollment Period. While these vary, they typically occur in situations that are out of the beneficiary’s control. Examples include such things as moving out of service area or an insurance company filing for bankruptcy.

Finally, it’s worth noting that Medicare Advantage plans may change their benefits each year with the federal Medicare, which means that each year the plan could change its offerings to beneficiaries–or the plan could be dropped entirely. If you’re ready to start browsing plan options, a representative from Mayberry Advisors would be happy to speak with you and provide you personalized assistance with your Medicare coverage needs.