Medicare Part C is most commonly known as Medicare Advantage. Medicare Advantage or “MA” plans are sold by Medicare-approved private insurance companies. They offer a second way to get Medicare Part A and Part B coverage.
The Medicare Advantage plans are administered by private carriers that are contracted with the federal government and must follow the guidelines set by Medicare. Most Medicare Advantage plans use provider networks that you must choose from. It’s common for MA plans to include Part D prescription drug coverage.
One attractive aspect of Medicare Advantage is that many of these plans offer additional services and benefits you won’t find in Original Medicare, such as vision, dental, and hearing coverage. This makes it a comprehensive solution to your health insurance needs.
What does Medicare Advantage cover?
Medicare Advantage will provide all of your Part A and Part B benefits, not including clinical trials and hospice services. MA plans must cover all emergency, urgent care, and medically necessary services that Original Medicare covers.
Most Medicare Advantage plans offer additional benefits that Original Medicare doesn’t cover, such as:
- Dental coverage
- Vision coverage
- Caregiver counseling and training
- Housekeeping
- Prescription drug coverage
- Over-the-counter benefits
- Monthly food cards
- Gym memberships
Every plan is different, so you’ll have to consult each plan’s summary of benefits to compare your options.
How Much Does Medicare Advantage Cost?
Some Medicare Advantage plans have premiums as low as $0. However, this does not mean the plans are free. Medicare pays a monthly sum to the insurance carrier to provide your care, which is how insurance carriers are able to offer plans at a $0 premium.
Understanding the costs associated with Medicare Advantage is essential to making an informed decision. While the allure of added benefits can be tempting, it’s crucial to balance them against the associated expenses. Let’s talk about some of the potential costs that come with Medicare Advantage plans.
- Deductibles: This is the amount you need to pay for covered health care services before your insurance plan starts to pay. For example, if your deductible is $500, your plan won’t pay anything until you’ve met the $500 deductible for covered services.
- Copays and coinsurance: These represent your share of the costs for a medical service. A copayment is a fixed amount you pay for a service. Coinsurance is a percentage of the cost of services.
- Maximum out-of-pocket: This is a cap set by the insurance carrier. It limits what you’ll pay out-of-pocket in a calendar year. After you reach this limit, the plan will pay 100% of your covered costs for the rest of the year.
Remember that on top of these costs, you are still responsible for paying the Part B premium.
Types of Medicare Advantage Plans
Medicare Part C plans cater to a diverse range of enrollees by offering several different kinds of plans, each with unique features, network rules, and costs.
Health Maintenance Organization (HMO)
These plans require members to use a specific network of doctors and hospitals. To see a specialist, you usually need a referral from your primary care physician. The primary distinction of an HMO is that, barring emergencies, any care received outside of the network will not be covered. While HMOs usually come with lower premiums and out-of-pocket costs, they require more coordination and adherence to the network.
Preferred Provider Organization (PPO)
PPO plans stand out due ot the flexibility they offer in choosing healthcare providers. While you can see any doctor or specialist (even without a referral), it’s cheaper to see one within the network. Consequently, PPOs might have slightly higher premiums and costs.
Private Fee-for-Serivce Plans (PFFS)
With a PFFS plan, you are not restricted to a particular network. You can consult any doctor or specialist, as long as they agree to the plan’s payment terms. There is no guarantee that every provider will accept these terms, so enrollees must confirm acceptance prior to any treatment.
Special Needs Plan (SNP)
SNPs design their benefits, provider options, and drug formularies tailored to the groups of people they serve. There are three kinds of SNPs: Dual-Eligible (D-SNP), Chronic Condition (C-SNP), and Institutional (I-SNP). You must meet the eligibility criteria of each in order to enroll.
Medical Medicare Savings Account (MSA)
MSA plans offer a combination of a high-deductible insurance plan paired with a medical savings account. The insurance carrier makes a deposit into the account, which beneficiaries can use toward their healthcare expenses. Though these plans come with a higher deductible, once that’s been reached, the MSA plan covers all approved subsequent expenses. MSA plans do not have network restrictions.
Eligibility for Medicare Advantage
All Medicare beneficiaries are eligible for Medicare Advantage. As long as you are enrolled in both Medicare Part A and Part B, you can purchase a Medicare Advantage plan. In addition, you can only enroll in plans within your residential zip code.
Another common question we get asked about Medicare Advantage eligibility is if health status is an issue. Medicare Part C plans do not ask any health questions on their application. Your current or past health history does not matter, and you will not face any waiting periods.
Medicare Advantage Enrollment Periods
The process of joining or changing Medicare Advantage plans is governed by specific enrollment periods. You cannot join or change your plan outside of the following enrollment periods.
- Initial Enrollment Period (IEP): This is the 7-month window that begins three months before the month you turn 65, includes your birthday month, and extends for three months after your birthday month. If you are eligible for Medicare due to a disability, your IEP begins on the 25th month or your disability benefits.
- Annual Enrollment Period (AEP): Occurring every year from October 15 through December 7, AEP is a period when you can change your Medicare Advantage plan, enroll in Medicare Advantage for the first time, or switch back to Original Medicare. You may also change your Part D plan during AEP.
- Medicare Advantage Open Enrollment Period: This enrollment opportunity runs from January 1 through March 31 each year. During this time, if you are already enrolled in a Medicare Advantage plan, you can make a one-time change to a different MA plan or switch back to Original Medicare.
- Special Enrollment Period (SEP): In certain situations, you might be allowed to join, switch, or leave a Medicare Advantage plan outside of the usual enrollment periods. Some situations that might qualify you for an SEP include moving outside of your plan’s service area, losing your current coverage, or if your plan changes its contract with Medicare.
- 5-Star Special Enrollment: If a 5-star Medicare Advantage plan becomes available in your area, you can switch to that high-performing plan anytime between December 8 and November 30 of the following year.
Find Medicare Advantage Plans Near You
Choosing the right health insurance plan is more than just a financial decision; it’s about ensuring you get the care you support and deserve in your golden years. Medicare Advantage offers an alternative to Original Medicare, combining essential health coverage and additional benefits that will enhance your quality of life.
But how do you find the best Medicare Advantage plans in your vicinity? You work with a Medicare advisor near you.
Explore your options with Bobby Brock Insurance. Don’t wait for the next enrollment period to catch you unprepared. Dive into the research now, consult with our experts, and make an informed choice about your health’s future.
