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Learning Center > What Is Medicare Advantage And How Does It Work?

What Is Medicare Advantage And How Does It Work?

What Is Medicare Advantage And How Does It Work?

Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. When you enroll in a Medicare Part C plan, your benefits are offered and administered by a private insurance company and these private insurance companies must comply with many rules and regulations set by the Medicare program. So whether you’re already in a Medicare Advantage plan, curious about them, or you’ve never heard of them, this in depth guide is for you.

Who Qualifies For Medicare Advantage?

To qualify for Medicare Advantage, you must be enrolled in Original Medicare Parts A and Medicare Part B. You also must continue to pay your Part B premium in order to keep your Medicare Advantage coverage.

There are no age restrictions for Medicare Advantage plans. If you’re enrolled in Part A and B before age 65 due to a disability or chronic condition, you’re still eligible for Medicare Advantage coverage.

Enrolling In Medicare Advantage For The First Time

If you’re turning 65, you can enroll in Medicare Advantage during your Initial Enrollment Period (IEP). Your IEP lasts for 7 months, which begins 3 months before your 65th birthday, includes that birthday month, and ends 3 months after you turn 65.

If you’re interested in signing up for a Medicare Advantage plan, there are three ways to do it. You can sign up for Medicare Advantage during your initial enrollment period around your 65th birthday, or during an annual enrollment period afterward. If you’re enrolled in Medicare Advantage and want to change to a different MA plan, you can take advantage of the Medicare Advantage open enrollment period.

If you’re under 65, your first chance to enroll in Medicare Advantage starts:

  • After your 24th month of receiving Social Security disability benefits, or
  • At any age if you have Amyotrophic Lateral Sclerosis (ALS), also called Lou Gherig’s Disease, or if you have End-Stage Renal Disease (ESRD).

Changing Your Medicare Coverage During AEP

The Medicare Open Enrollment Period, also called the Medicare Annual Enrollment Period or Annual Election Period, is a good time to decide whether Medicare Advantage or Original Medicare is right for you.

Keep in mind that Medicare Advantage plan benefits can change annually. So if you have a MA plan, you should check to make sure the plan still meets your needs.

Here are the actions you can take during AEP:

  • Change from Original Medicare to a Medicare Advantage plan.
  • Change from one Medicare Advantage plan to another.
  • Disenroll from your Medicare Advantage plan and go back to Original Medicare.
  • Change from one prescription drug plan (Medicare Part D) to another.
  • Enroll in a prescription drug plan.
  • Cancel your prescription drug coverage.
  • If you enroll in, or switch your Medicare Advantage insurance during AEP, your new coverage will be effective on January 1st of the following year.

You may also be able to enroll in a Medicare Supplement plan if you drop your Medicare Advantage coverage during AEP.

Medicare Advantage Open Enrollment Period

If you’re enrolled in a Medicare Advantage plan, you have access to another enrollment period beyond AEP: The Medicare Advantage Open Enrollment Period (MA-OEP).

MA-OEP runs from January 1 to March 31 of each year. During the MA-OEP, you can:

  • Change from one Medicare Advantage plan to another.
  • Drop Medicare Advantage, and return to Original Medicare.
  • Add a Prescription Drug Plan if you return to Original Medicare.

It’s important to keep in mind that the MA-OEP is only for people who already have a Medicare Advantage plan. If you change plans during the MA-OEP, your new coverage will be effective on the first day of the month after you enroll.

How Do Medicare Advantage Plans Work?

Medicare Advantage health care plans work like the employer-sponsored health insurance plans you may be used to from your previous or current job.

Medicare Advantage plans provide comprehensive coverage, and you usually need to stay in-network to receive care. You’ll typically have some out-of-pocket expenses when you receive services and procedures under your Medicare Advantage policy. These costs typically come in the form of copayments or coinsurance that you’ll pay to your provider when you receive care.

An important point to remember is that all Medicare Advantage plans have an annual out-of-pocket (OOP) maximum that limits the total amount you can spend in any year. But you do not have an OOP with Original Medicare.

What are the Advantages and Disadvantages of Medicare advantage Plans?

What are the benefits and drawbacks of Medicare Advantage? There are pros and cons to having this type of plan. Let’s take a look at them:

Advantages of Medicare Advantage:

  • There’s a maximum cap on out-of-pocket costs for each year
  • Most MA plans include prescription drug coverage
  • There are often additional benefits included, such as vision and dental coverage, health club discounts, and more
  • You have more clarity on your out-of-pocket costs because MA plans generally have copayments rather than coinsurance percentages like Original Medicare
  • Some MA plans are available at no additional cost above your Part B premium

Disadvantages of Medicare Advantage:

  • Plans may have a limited network of doctors focused in a single geographic area
  • You may have to coordinate your care through a primary care physician and get referrals to specialists
  • There may be no insurance coverage for doctors outside the plan’s network, including when you travel
  • You may not be able to combine your health coverage from retirement benefits with MA, and choosing an MA plan may cause you to lose other coverage and be unable to get it back

What is the Difference Between Original Medicare and Medicare Advantage Plans?

The primary difference between these programs is that Medicare Advantage is an alternative to Original Medicare. When you join a Medicare Part C plan, you no longer receive your Medicare benefits through Original Medicare.

Medicare Advantage plans are offered and administered by private insurance companies. But these private insurance companies must comply with many rules and regulations set by the Medicare program.

What Does Medicare Advantage Cover?

Medicare Advantage plans provide coverage that matches Original Medicare Parts A and B. Generally speaking, your Medicare Advantage plan will cover the same service or procedure as Original Medicare. But there is one exception to this rule, which we’ll cover below.

Medicare Advantage plans cover the following services.

Medicare Part A Services

Medicare Part A covers services that take place in healthcare facilities or institutions like:

  • Inpatient hospital stays
  • Skilled nursing services (not room and board)
  • Hospice care
  • In-home care

Note: Hospice care is usually not covered by Medicare Advantage plans. Instead, hospice care is covered under Original Medicare, even if you’re enrolled in a Medicare Advantage plan. However, a new test program in 2021 will explore Medicare Advantage plans providing hospice benefits.

Medicare Part B Services

Medicare Part B services and procedures are considered more routine and non-emergency in nature than Part A. Common Medicare Part B services include:

  • Doctor’s visits, including specialists
  • Physical and occupational therapy
  • Lab and diagnostic testing services like blood work and x-rays
  • Durable medical equipment
  • Mental health services
  • Ambulance services
  • Some cancer treatments, including chemotherapy

As mentioned, Medicare Advantage plans cover all of these services with the exception of hospice care.

Medicare Part D Services

Most Medicare Advantage plans offer prescription drug coverage. These plans are also known as Medicare Advantage Prescription Drug Plans (MAPDs), and they include Medicare Part D.

Medicare Advantage Extra Coverage

When considering Medicare Advantage pros and cons, it’s essential to take extra benefits that Medicare Advantage could offer to you. Many of these benefits are not provided through Original Medicare.

  • Fitness programs: SilverSneakers, gym memberships, and fitness trackers.
  • Vision care: Eye exams, contact lenses, and sometimes eyeglass frames.
  • Hearing care: Exams and often discounted hearing aids.
  • Dental coverage: Some plans have basic dental benefits built in, others offer dental coverage for an extra premium.
  • Transportation: Rides to and from medical appointments.
  • Meal Deliveries: For qualified people returning home from the hospital or skilled nursing facility
  • Telemedicine services and virtual healthcare.

Note: Medicare Part C plans have the ability to choose which, if any, extra benefits to offer. These insurance companies may also make changes to their Medicare benefits and offerings each year.

What Types Of Medicare Advantage Plans Are Available?

There are 6 types of Medicare Advantage plans, including:

  • Medicare Advantage HMOs (Health Maintenance Organizations)
  • Medicare Advantage PPOs (Preferred Provider Organizations)
  • Medicare Advantage PFFS (Private Fee-For-Service Plans)
  • Medicare Advantage SNP (Special Needs Plans)
  • Medicare Advantage HMO-POS (HMO Point-Of-Service Plans)
  • Medicare Medical Savings Plans (MSPs)

Who Is Medicare Advantage Good For?

You should consider enrolling in Medicare Advantage if:

  • You want to put a cap on your total out-of-pocket spending under Original Medicare.
  • You want prescription drug coverage without paying for a separate Part D drug plan.
  • You need some of the extra benefits (vision, hearing, private home aides) that come with many Medicare Part C plans.
  • You don’t want to pay for Medicare Supplement (Medigap) plans.
  • You don’t mind using a network of doctors and facilities.
  • You don’t mind needing referrals to see specialists.
  • You don’t mind paying small copays each time you see a doctor.

How Much Does Medicare Advantage Cost?

Medicare Advantage plans have several costs associated with them. Before we dive into each cost, it’s important to remember that you always have to pay your Part B premium in order to have Medicare Advantage.

Now, some Medicare Advantage plans offer a benefit that covers part, or all, of your Part B premium. But check the plan benefits closely to see if this is offered by a specific Medicare Advantage plan.

Beyond this Part B premium, you might face the following Medicare Advantage plan costs:

  • Monthly premium
  • Annual deductible
  • Copayment
  • Coinsurance

You might have a monthly premium for your Medicare Advantage plan, but many plans do not have them. If they do, these premiums tend to be low.

Some Medicare Part C plans have an annual deductible, but again, many do not. If your plan does have an annual deductible, this means you’ll have to pay a certain amount before the plan begins paying benefits. Note that there may be separate deductibles for drug coverage and medical benefits.

Beyond premiums and deductibles, the most common expenses you’ll have with Medicare Advantage plans are copayments and coinsurance. These two terms are referred to as “cost-sharing.” This is what you’ll pay out of pocket when you receive covered services. All the amounts you pay during the year count towards your annual out-of-pocket cap.

Examples Of Medicare Advantage Costs

Let’s look at 3 examples of how these Medicare Advantage costs work in a Medicare Advantage HMO plan.

(Note: These costs are not the actual costs for any specific plan, but rather, in the range of costs for plans that you may have access to.)

Scenario 1: Medicare Part B Services

  • You injure yourself shoveling snow on your property, and you go to the doctor for an examination.
  • You’ll pay a copay of $20 to see your primary care physician who then refers you to an orthopedic specialist.
  • Your orthopedic specialist charges you a $35 copay for the office visit and wants you to get x-rays.
  • You pay a $50 copay for the x-rays. Fortunately, nothing is broken or torn, so your specialist refers you to physical therapy.
  • You pay a copay of $40 for four physical therapy sessions.
  • Your total out-of-pocket spending for this injury is $265, spread out over a month-long period. All of these costs count towards your Medicare Advantage out-of-pocket maximum.

Scenario 2: Medicare Part A & B Services

You experience the symptoms of an irregular heartbeat, so you’re admitted to the hospital as an inpatient. You spend two nights in the hospital.

  • You pay a copay of $300 per day, which amounts to a total of $600.
  • After you’re released from the hospital, you continue to see a cardiologist, and you pay a $35 copay to see this specialist each time you visit.

Scenario 3: Cancer

You’re diagnosed with a treatable cancer, and you’re given chemotherapy.

  • The copay for this treatment is 20% of the Medicare-approved cost.
  • Although 20% amounts to more than $20,000, you hit your annual out-of-pocket maximum, so your costs are capped at $5,900 for the year.

Medicare Advantage Plans

Medicare Advantage plans can be a great way to manage your out-of-pocket spending while enjoying extra benefits we covered, if you qualify. And they can offer some compelling advantages over Original Medicare, depending on your healthcare needs.

So if you'd like to learn more about Medicare Advantage plans in your area, call 800-620-4519 to reach a licensed insurance agent who may be able to guide you to the right plan for your needs. You can also try our online Medicare plan comparison tool.

What you should read next

The Medicare Annual Enrollment Period (AEP), sometimes called Medicare Annual Open Enrollment or the Medicare Annual Election Period, runs from October 15 to December 7 each year. This is the time period in which Medicare beneficiaries can make certain changes to their Medicare plans, which we will cover below. Those plan changes would then become effective on January 1. But if Medicare beneficiaries are satisfied with their current Medicare plans, they don't have to take any action during Medicare AEP and there are no penalties involved. Medicare plan details can change annually, though, so it's wise to review your Medicare coverage each year. Overview of Medicare Enrollment Periods It's important to know that the Medicare Annual Enrollment Period is different from other Medicare enrollment periods. Here’s a quick overview of the differences: Annual Enrollment Period (AEP): Any changes to Medicare or Medicare Advantage plans Initial Enrollment Period (IEP): Only happens around your 65th birthday, any changes to Medicare or Medicare Advantage plansOpen Enrollment Period (OEP): Applies only to those with Medicare Advantage, who can change Medicare Advantage plans or drop them and return to Original MedicareGeneral Enrollment Period (GEP): Open enrollment period to join Medicare Part A and B.Special Enrollment Period (SEP): Occurs if you have eligible life changes that mean you need to change your plan before the next annual enrollment period.Be sure to visit our guide to different enrollment periods to learn more.What’s the Difference Between Medicare AEP and the Medicare General Enrollment Period?The Medicare Annual Enrollment Period is sometimes confused with the Medicare General Enrollment period, which is January 1 to March 31 each year. It’s important to understand the differences between the two enrollment periods.The Medicare General Enrollment Period is for Medicare beneficiaries who didn’t sign up for Medicare Part A) or Part B when they first became eligible and aren’t eligible for a Medicare Part B special enrollment period. The AEP, however, is for beneficiaries who are already enrolled in Medicare and want to change their Medicare coverage.What Changes Can I Make During the Medicare Annual Enrollment Period?The first thing to know is that you cannot use the Medicare Annual Election Period to enroll in Medicare Part A or Part B for the first time.If you’re enrolled in Medicare Part A and Part B and you’d like to change your Medicare coverage, here are some things you can do during the Medicare AEP:Change from Original Medicare to a Medicare Advantage plan.Change from one Medicare Advantage plan to another.Disenroll from your Medicare Advantage plan and go back to Original Medicare.Change from one prescription drug plan (Medicare Part D) to another.Enroll in a prescription drug plan.Cancel your prescription drug coverage.5 Tips to Prepare for the Medicare Annual Enrollment PeriodThere are many Medicare insurance carriers and plan options, but there are several steps you can take to be a savvy shopper and choose the right plan for your unique needs.1. Mark Your CalendarThis may seem like an obvious tip, but it’s worth mentioning: Mark your calendar for October 15 through December 7 if you’d like to make a change to your Medicare plan.You might even set aside a few hours to research and compare Medicare Advantage plans and Prescription Drug plans ahead of October 15. These plans announce their benefits for the next year starting on October 1.Writing down these Medicare AEP dates and to-dos will help you to commit to these priorities.2. Review Your Medicare Annual Notice of ChangeYou’ll receive lots of information over the next month or so prior to and during AEP, so if you’re currently enrolled in a Medicare Advantage or Prescription Drug Plan, the Annual Notice of Change (ANOC) is one piece of mail you’ll want to read.Your Medicare plan will mail your Annual Notice of Change letter to you by September 30. The ANOC letter will inform you of most changes to your Medicare health plan, including coverage and benefits that will take effect on January 1, 2022.Each year, your Medicare health plan sets the amounts it will charge you for premiums, deductibles and other services. Medicare doesn’t set these rates - but your insurance company does. With this in mind, the amounts you pay could change each year.While evaluating your current Medicare plan, you may want to ask yourself questions like:Did the plan cover the services I needed?Did I use out-of-network providers?Did I spend more out of pocket than I originally anticipated?Has something changed with my health (new diagnosis, new prescriptions, etc.)?The ANOC will also provide a side-by-side comparison of your current plan and next year’s plan benefits, costs and other changes (if any).Moral of the story: Don’t toss this piece of mail aside. Always review your ANOC to ensure your plan continues to meet your needs on an annual basis. And if you don’t receive your ANOC by September 30, contact your Medicare insurance company.3. Make a List of What’s Important to Your HealthKeeping a list of what’s important to your health is an invaluable way to prepare for the Medicare Annual Enrollment Period.Start by writing down all of your doctors, preferred health care facilities and hospitals, and prescription drugs, if you take any.We also recommend making a list of value-added benefits that may fit your health, lifestyle and budget.For example, you may be someone who likes to keep active and have social interaction. So a fitness program like SilverSneakers, which gives you access to a network of gyms and other programs, might be a good fit for you. A Medicare Advantage plan may provide these types of fitness or wellness programs.Another thing to consider is whether or not you have an elective surgery planned for 2022. If so, you’ll want to check your hospital-specific benefits under your current Medicare Advantage plan.4. Check Your Plan’s Drug FormularyYour Medicare plan’s drug formulary will not be included in your Annual Notice of Change, so be sure you call your insurance customer service representative to see if your prescription drugs will be covered for the 2022 plan year.If your prescription drugs aren’t covered, it’s wise to use the Medicare Annual Enrollment Period to find a plan that does cover them.5. Talk To Your DoctorAnother “Medicare must-do” is to make sure all of your doctors and healthcare facilities will remain in network with your current Medicare plan. If they aren’t, you may want to take advantage of the Medicare Annual Enrollment Period.So be sure to ask your doctor if he or she plans on changing health plan affiliations over the next year.What Changes Can I Make During the Medicare Annual Enrollment Period?The first thing to know is that you cannot use the Medicare Annual Election Period to enroll in Medicare Part A or Part B for the first time.But if you’re enrolled in Medicare Part A and Part B and you’d like to change your Medicare coverage, here are some things you can do during the Medicare Annual Election Period:Change from Original Medicare to a Medicare Advantage plan.Change from one Medicare Advantage plan to another.Disenroll from your Medicare Advantage plan and go back to Original Medicare.Change from one prescription drug plan (Medicare Part D) to another.Enroll in a prescription drug plan.Cancel your prescription drug coverage.What Are The Benefits of a Medicare Advantage Plan?Understanding your Medicare plan options - starting with a Medicare Advantage plan - is a smart first step to take because you can switch, enroll into or dis-enroll from Medicare Advantage plans during AEP.Medicare Advantage plans, otherwise known as “Medicare Part C” or “MA Plans,” bundle Original Medicare (Parts A and B) services into one plan. While Original Medicare offers you a number of benefits, it may not cover health and medical services you might need.One major change happening for the 2021 plan year is that people with End Stage Renal Disease (ESRD), also known as kidney failure, will now have the option to enroll in a Medicare Advantage plan. The Centers for Medicare & Medicaid Services (CMS) estimates that more than 80,000 people living with ESRD will enroll in a Medicare Advantage plan by 2026 - a significant increase of 63%.What Are Medicare Advantage Special Needs Plans?Medicare beneficiaries also have access to Medicare Advantage plans designed for unique needs. These are called Special Needs Plans (SNPs). Like other types of Medicare Advantage plans, SNPs vary based on location.You may be able to switch to a Special Needs Plan during the Medicare Annual Enrollment Period if one of these situations apply:You’ve been diagnosed with a serious medical condition by a doctor. There are SNPs for certain chronic conditions, such as kidney and heart failure, diabetes and dementia. Services are tailored to the specific condition the plan covers.You need or have received skilled nursing care for at least 90 days at your home or at an institution, such as a nursing home or long-term care facility.You qualify for both Medicare and Medicaid. Medicaid eligibility is based on your income and assets. If you qualify, Medicaid will pay most of the costs for your Medicare Special Needs Plan.Special Needs Plans include all the same benefits as regular Medicare Advantage plans, plus some expanded coverage.For example, all Special Needs Plans must include prescription drug coverage, which is usually tailored to the specific condition the plan covers. Although most regular Medicare Advantage plans include prescription drugs, some do not.Some SNPs also provide a care coordinator to help you stay on track with your doctor appointments and treatment plan.Changes in Income Due to Coronavirus (Covid19)?The coronavirus crisis has affected the financial well-being of many Americans, including those on Medicare. If you’ve experienced a decrease to your income or assets, the Medicare AEP 2020 season is a great time to switch to a more affordable plan.If you have limited income, you might qualify for extra savings on Medicare costs through these programs:Medicare Savings Programs. These programs help pay for some of your Medicare Part A and Part B out-of-pocket costs, such as copays, deductibles and premiums. Most programs are for Medicare beneficiaries who also qualify for Medicaid. And as mentioned, Medicaid covers the majority of your costs when you join a Medicare Advantage Special Needs Plan. You can check if you qualify through your local Medicaid office.Medicare Extra Help. Extra Help reduces your Medicare prescription drug plan costs. You should contact Social Security to check your eligibility for Extra Help if you have an existing Medicare drug plan or you join one during AEP.How To Enroll During the Medicare Annual Enrollment PeriodTo enroll in an eligible plan during the Medicare Annual Enrollment Period, you can visit our comparison tool. Or, you call (855) 651-5094 to talk to a licensed insurance agent to get help enrolling in Medicare.Whatever option you choose, be sure to have 3 items handy before you enroll in a plan or make changes to your current plan during AEP:Your Medicare cardYour list of doctors, prescriptions and what is important to your healthPen and paper to take notesHow To Find A Medicare Advantage or Prescription Drug Plan During AEPYou don’t have to go it alone when choosing a Medicare Advantage plan or Prescription Drug Plan. We’re here to help you navigate the Medicare Annual Enrollment Period through a number of ways, including:Our licensed agents: 1-800-620-4519Our Medicare plan comparison toolOur online Medicare resourcesView Our 2022 Medicare Annual Enrollment GuideThe experts at TogetherHealth have developed a 2022 AEP Readiness Guide to help you prepare for the Medicare Annual Enrollment Period so you can make an informed choice for your healthcare needs next year.
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