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.