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Medicare Advantage FAQs

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The Pros of Choosing Medicare Advantage

When choosing Medicare coverage, you may select Original Medicare or a Medicare Advantage plan, which is also known as Medicare Part C. Original Medicare includes Part A (hospital coverage) and the optional, though strongly recommended, Part B (doctors and other medical service coverage). Original Medicare is administered directly through the federal government, while Medicare Advantage is offered by private insurance companies that contract with the government. There are many factors to consider when you’re making a decision. Use the following information to understand the advantages of choosing a Medicare Advantage plan.
 

Pro No. 1: More Services

Medicare Advantage plans have more flexibility than Original Medicare in the range of services that they cover. By law, Medicare Advantage plans must cover all the services that Original Medicare does, but they are also able to offer more coverage. These additional benefits can include hearings aids, eyeglasses, on-call registered nurses, in-home health visits and gym memberships. Many Medicare Advantage plans also include Part D (prescription drug coverage) within their plans. If you choose to go with Original Medicare and want prescription drug coverage, you will also have to purchase a separate Part D plan, offered by private insurance companies. Medicare Advantage plans also have more flexibility than Original Medicare in covering non-medical supplemental benefits, such as non-emergency transportation to medical appointments, delivery of meals to the home, modifications to the home for members with limited mobility and non-professional in-home care, such as assistance with bathing, dressing and cooking.

 

Pro No. 2: Low or No Premiums

Many Medicare Advantage plans have low premiums, while others have none. The government pays for parts A, B, and C, but you pay a premium for Part B that is usually deducted from your Social Security. Private insurers may or may not charge an additional premium for Part C depending on the plan chosen. Part C premiums range from zero dollars to the low $300s per month. Depending on the plan selected, you can receive additional benefits at no extra cost to you.

 

Pro No. 3: Carefully Selected Providers

Medicare Advantage plans save money in part by selecting low-cost, high-quality providers for their members. Many Medicare Advantage plans, particularly HMOs, work with a “care team” led by your primary care physician that includes other physicians, nurses and physician assistants to provide coordinated care. Research cited by the Agency for Healthcare Research and Quality has shown that a “care team” leads to better quality of care and more patient safety.

 

Pro No. 4: Lower Deductibles and Copayments

A deductible is the amount you have to pay for health care services or prescriptions before your insurance provider will begin to pay. Copayments, or copays, are fixed prices that you pay for specific health care services like visits to your doctor’s office or urgent care center.  If the Medicare Advantage plan you choose has deductibles and copays, compare them and consider your health care needs as they will vary from plan to plan. A health insurance broker who represents many plans can provide you with information about all the plans available to you.

 

Pro No. 5: An Out-of-Pocket Cap

A major consideration is that there is no out-of-pocket limit for Original Medicare. With Original Medicare, the medical costs that you are responsible for paying out of pocket are not capped – they just keep adding up in the course of a calendar year and may, in the case of grave illnesses, add up to hundreds of thousands of dollars. Medicare Advantage plans, in contrast, have an out-of-pocket limit. After you have paid that much, you pay nothing else for the year for covered services, no matter how high your actual expenses are. 

 

Pro No. 6: Carefully Coordinated Care

Some Medicare Advantage plans allow you to visit any provider for any purpose. Most, however, are health maintenance organizations (HMOs) and require you to select a primary care physician (PCP) who works hard to get you to the right provider for the right reason at the right time. Care is coordinated through your PCP to ensure that you receive the proper services and are not over-diagnosed and over-treated. Medicare Advantage plans organize access to providers in one of three ways:

  1. An HMO model, in which a single provider coordinates your care and makes necessary referrals to specialists within a predetermined network of providers 
  2. A preferred provider organization (PPO) model, in which you can go to an in-network or out-of-network provider, without a referral from a PCP, but have a higher deductible and/or copay for going out of network
  3.  A private fee-for-service (FFS) model, in which you typically can go to any provider that accepts the plan’s payment terms 

Generally, premiums and copayments for an HMO model plan are lowest because going through a single provider enables them to exert more control over costs. Premiums are generally higher for PPO and FFS plans. HMO-type plans can produce considerable savings for Medicare and their patients while also delivering care that is high quality.

 

Pro No. 7: You Can Change Plans Twice a Year

All Medicare beneficiaries can change their Medicare coverage during Medicare’s annual election period (Oct. 15 - Dec. 7 of each year). If you enroll in a Medicare Advantage Plan and decide you are unhappy with the plan you selected, you can switch to another plan or go back to Original Medicare between Jan. 1 and March 31 of each year.

 

Summing Up

You have a variety of choices to make when considering your Medicare options. Medicare Advantage plans provide more services, more coordinated care and more value than Original Medicare. Working with an insurance broker who represents multiple Medicare Advantage plans gives you the best chance at finding a high-quality plan that is easily affordable for you.