¹ Based on more than 111,000 eHealth Medicare visitors who used the company's Medicare prescription drug coverage comparison tool during Medicare's 2020 Annual Election Period (October 15 – December 7, 2019).
In the United States, Medicare is the federal health insurance program specially designated for individuals over 65 years of age, younger individuals with qualifying health conditions, and a number of patients with end-stage kidney disease. There are different parts (A, B, and D) to the Medicare program that provide specific coverage options. In some scenarios, individuals may choose to swap out what’s known as “Original Medicare” for an alternative, often in the form of Medicare Advantage plans.
Although Medicare Advantage plans can expand coverage opportunities for patients, there are many important details to understand. Since sorting through the options can feel overwhelming, it’s beneficial to have one specific resource that provides answers and insight.
In this complete guide to Medicare Advantage Plans, you’ll develop a better understanding of:
A Medicare Advantage plan is simply an alternative to the traditional Medicare program. Instead of offering separate parts for designated medical care and services, Medicare Advantage is more comprehensive, or “all-in-one.” In addition to the standard options that Original Medicare covers, Medicare Advantage plans often tack on additional benefits such as hearing, vision, dental, and other types of routine or preventative care.
With traditional Medicare, participants have to enroll in separate plans. These are most often designated as:
In contrast, Medicare Advantage plans are not broken down in these different segments. The elements listed above are bundled together within one core plan. Additionally, the options for Advantage plans often include things that many patients have to fund out-of-pocket with traditional medicare. This list includes things like:
The most important distinction with Medicare Advantage plans is that they are provided through private health insurance companies. Fortunately, once you are approved for Medicare coverage, you are likewise approved for an Advantage plan.
The private insurers involved in this exchange contract with Medicare to provide the standard benefits of Part A and Part B. Any private insurer that offers an Advantage plan must:
Medicare Advantage plans can come in many different forms, although each one must still adhere to the terms and requirements of the Medicare program. These types include:
These distinctions are made by each individual insurance provider and may have an impact on which providers you see, how you pay, and what your coverage options could include.
As with any medical coverage or health insurance, you can realistically expect to pay for your Medicare Advantage plan benefits. Many times, policyholders want to know what they’re getting into before agreeing to a particular plan. Below are some of the regular costs that you can anticipate when you choose Medicare Advantage.
Before you can move forward with choosing a Medicare Advantage plan, it’s important that you’re aware of your eligibility and ability to enroll. You can locate more information about your specific age and situation on Medicare.gov.
Once enrolled, you simply need to select how you want to get Medicare coverage. As mentioned previously, this can come in the form of Original Medicare or an Advantage Plan. Unfortunately, patients with end-stage kidney disease cannot opt for an Advantage plan.
Additionally, always be sure that you are choosing the right coverage option based on your state of residence. As Medicare Advantage plans are private, they can vary by state. The Medicare Plan Finder will help you discover coverage options where you live.
Although each Medicare Advantage plan should provide qualifying and sufficient coverage, not all plans are created equal. While each option does need to satisfy the federal standards of Original Medicare, there may be differences and nuances between plan options. Below are a few things to consider as you weigh your personal choices.
As with any major financial or medical decision, different Medicare options have their own unique pros and cons. Many of these factors might depend on a person’s individual medical background or current treatment needs. Below are several advantages to choosing a Medicare Advantage plan over Original Medicare.
Many individuals find that the costs associated with coverage are less through Medicare Advantage as compared to Original Medicare. This is especially true if you rely on things like routine lab visits or medical equipment.
Based on the Advantage plan you choose, you may have no premium amount or low-cost deductibles. When compared to the co-insurance options found in traditional Medicare, some patients may come out paying much less through an Advantage option.
Additionally, there are annual caps on out-of-pocket amounts. While this isn’t a standard amount on each individual Medicare Advantage plan, it often provides substantial yearly savings to many members.
One of the frustrating things about the traditional Medicare structure is that it often requires additional or supplemental coverage to fill in the gaps. Patients need Part D in order to get prescription drugs, and gap coverage is also used to supplement low or missing coverage for certain patients.
With Medicare Advantage, patients can benefit from things like vision, dental, and hearing services. There is no need to purchase outside prescription drug coverage, and the overall benefits may be better.
Medicare Advantage plans are considered “managed care,” since they take place within a network of providers who operate under a contract. If you use an HMO Advantage plan, you’ll be required to designate a Primary Care Physician (PCP) who often coordinates your medical care and oversees routine and preventative appointments.
If you leverage prescription benefits, you may also receive a medication therapy management provider. These services are designed to help you approach your health from a holistic perspective, which often results in better communication among doctors and care providers.
When you opt for an Advantage plan, you’ll typically have one plan administrator to work with. This simplifies the process of communicating about your coverage and getting important information as it relates to your benefits, expenses, and other important details.
Unlike Original Medicare which includes distinct and separate “Parts,” Advantage plans allow you to house all of your medical coverage under one roof and to communicate with only one insurance provider for all of your basic needs and questions.
Although Medicare Advantage Plans work out well for many individuals, others may find that there are certain disadvantages as well. Below are some of the cons associated with choosing Medicare Advantage over a traditional option.
Insurance Ranked offers an expansive collection of resources and comparisons to help individuals make the best health insurance decisions at every age and stage. By using our comparisons and other step-by-step guides, you’ll be better equipped to choose the right health insurance plan for yourself or a family member.
By now, you’ve learned more about what makes Medicare Advantage plans different from traditional Medicare plans. You’ve also learned how to prepare for enrollment and how to compare pros and cons. Below are some of the most common FAQs that individuals have pertaining to Medicare Advantage.
If you are enrolled and approved for Original Medicare, you can join a Medicare Advantage plan. However, since the options differ by state, you must verify your plan’s service area to ensure that it aligns with your place of permanent residence. If you have Medicare Part A and B and do not have end-stage renal disease, you are eligible.
Choosing a Medicare Advantage plan is certainly not required. You’ll still have access to important benefits under traditional Medicare, but an Advantage plan is a bit more comprehensive. Review the list of positives in this article to see if any apply to your unique situation.
Typically, no. Medicare Advantage is often recognized as being more comprehensive in terms of coverage and options. At a base level, Medicare Advantage options must offer the minimum of what Original Medicare offers. That being said, most Advantage plans also offer additional coverage options that some patients find superior.
First, it’s important to do your research up-front and to select the plan type and out-of-pocket amounts that work best for you. Additionally, you can take the time to secure pre-approvals and referrals when utilizing non-routine care from specialists.
Fortunately, many personalized and long-term care options are protected by Medicare regulations. This means that if you require treatments such as chemotherapy, dialysis, or skilled nursing care, you can’t be charged more for those services with an Advantage plan.