Medicare Advantage Plans

What Benefits Do Medicare Advantage Plans Cover?

Medicare Advantage plans cover the benefits provided by Original Medicare (Part A and Part B), which include:

• Inpatient hospital stays
• Outpatient care
• Doctor visits
• Lab tests
• X-rays

Many Medicare Advantage plans also offer extra benefits like:

• Prescription drug coverage (Part D)
• Dental, vision, and hearing coverage
• Fitness programs
• Over-the-counter allowances

How Much Does a Medicare Advantage Plan Cost?

The cost of a Medicare Advantage plan varies depending on the specific plan and your location. You'll pay a monthly premium, and may also have co-payments, co-insurance, and deductibles.

Am I Eligible for a Medicare Advantage Plan?

You may be eligible for Medicare Advantage if you:

1. Are enrolled in both Medicare Part A and Part B
2. Live in the service area of the Medicare Advantage plan you choose

When Can I Enroll in a Medicare Advantage Plan?

You can enroll in a Medicare Advantage plan during the following periods:

1. Initial Enrollment Period (IEP)

A 7-month period that begins 3 months before the month you turn 65 and ends 3 months after your birthday month.

2. Annual Enrollment Period (AEP)

Occurs every year from October 15^th to December 7^th.

3. Special Enrollment Periods (SEPs)

Medicare beneficiaries can make changes to their Medicare Advantage coverage outside of the standard enrollment periods. SEPs are available in specific situations, such as moving to a new location, life changes or issues with current Medicare plans that include:

UNSURE IF YOU QUALIFY FOR A SEP?

Learn about SEPs

1. Moving to a New Location

• Qualifying Conditions:

    You move to a new service area where your current plan is not available, or there are new plans available in the new area.

• SEP Duration:

    You can make changes starting the month before your move and lasting up to 2 months after.

2. Losing Current Coverage

• Qualifying Conditions:

    You lose other coverage, such as employer or union coverage, Medicaid, or Extra Help.

• SEP Duration:

    Typically, the SEP lasts for 2 months after you lose the other coverage.

3. Qualifying for a 5-Star Plan SEP

• Qualifying Conditions:

    A Medicare Advantage plan in your area has earned a 5-star rating.

• SEP Duration:

    You can switch to the 5-star plan once per year between December 8^th and November 30^th of the following year.

What Are the Different Types of Medicare Advantage Plans?

There are several types of Medicare Advantage plans, including:

1. Health Maintenance Organizations (HMO)

• Description:

    HMO plans require members to use a network of doctors, hospitals, and other healthcare providers. You generally need to choose a primary care physician (PCP), who manages your healthcare and provides referrals if you need to see a specialist.

• Coverage:

    HMOs often include prescription drug coverage (Part D). Except in cases of emergency or urgent care, services received outside the network are typically not covered.

HMO Plans usually work for beneficiaries who prefer coordinated care through a single network and are comfortable with using designated providers.

2. Preferred Provider Organizations (PPO)

• Description:

    PPO plans offer more flexibility in choosing healthcare providers. They have a network of preferred providers, but you can also see out-of-network providers at a higher cost.

• Coverage:

    You do not need a referral to see a specialist, and you have the option to receive care both in and out of network. However, out-of-network services usually have higher co-pays.

PPO Plans usually work for beneficiaries who want more freedom in choosing providers and are willing to pay more for out-of-network care when necessary.

3. Private Fee-for-Service (PFFS)

• Description:

    PFFS plans determine what they will pay providers and what the patient’s share will be for each service. Providers must accept the plan’s terms and conditions each time you receive care.

• Coverage:

    PFFS plans may have a network, but you are generally not required to use it as long as your provider agrees to the plan’s terms. Some PFFS plans include prescription drug coverage; if not, you may need to add a separate Part D plan.

PFFS Plans usually work for beneficiaries who prefer more flexibility in provider choice and are comfortable confirming provider acceptance of the plan’s payment terms, each visit.

4. Special Needs Plans (SNP)

• Description:

    SNPs are tailored Medicare Advantage plans designed for people with specific needs, such as those with certain chronic conditions, dual eligibility for Medicare and Medicaid, or institutional care needs.

• Coverage:

    SNPs provide benefits, provider choices, and prescription drug coverage designed to meet the unique healthcare needs of their members. Enrollees usually have a network, and care is often coordinated through a PCP or case manager.

SNP Plans usually work for beneficiaries with specific chronic conditions, dual eligibility, or requiring institutional care, who benefit from highly targeted and coordinated care.

How Do I Choose the Right Medicare Advantage Plan?

Choosing the right Medicare Advantage plan requires evaluating several key factors to ensure the plan meets your healthcare needs, budget, and preferences.

Some of the main factors to consider:

1. Coverage and Benefits

Different Medicare Advantage plans offer varying levels of coverage beyond the required Parts A and B services. Some include additional benefits like prescription drugs (Part D), dental, vision, hearing, fitness memberships, and wellness programs.

2. Costs

Medicare Advantage plans come with costs like monthly premiums, deductibles, co-pays, and out-of-pocket maximums. Costs vary between plans.

3. Provider Network

Most Medicare Advantage plans, especially HMOs and PPOs, use a network of doctors, hospitals, and healthcare providers. Plans generally have different costs for in-network versus out-of-network providers.

4. Prescription Drug Coverage (Part D)

Many Medicare Advantage plans include prescription drug coverage, but coverage varies, especially regarding which medications are included and at what cost.

QUESTIONS ABOUT MEDICARE PART D?

Learn about Prescription Drug Plans

5. Quality Ratings (Star Ratings)

Medicare assigns star ratings to Medicare Advantage plans based on quality and performance, covering categories like customer service, member satisfaction, and health management.

When comparing Medicare Advantage plans, it is essential to balance factors like cost, provider access, and extra benefits with your healthcare needs and lifestyle. By carefully reviewing these elements, you can choose a plan that aligns well with both your healthcare and financial goals.

A licensed insurance agent can assist you in comparing the Medicare Advantage plans available in your area based on the information above.

Is Medicare Advantage for me?

Whether or not you need Medicare Advantage depends on your individual needs and preferences. If you're looking for additional benefits like prescription drug coverage, dental, vision, and hearing coverage, or want to simplify your health insurance, an MA plan may be a good option. However, it's important to carefully compare plans to ensure you choose the one that best fits your needs and budget.

For more detailed information and personalized advice, speak to a licensed insurance agent.