Learn More About Medicare Advantage
How Medicare Advantage Works
Medicare Advantage plans are sold by private insurance companies, similar to an insurance policy you may have had before switching to Medicare. Medicare Advantage plans replace Original Medicare but are required by the federal government to offer at least the same level of coverage. You won’t lose any coverage by switching to Part C, and you will still be enrolled in the Medicare program.
Medicare Advantage plans are available in a variety of different types. Plan specifics, such as provider networks, coverage rules, premiums, and costs vary depending on the insurer and your location. For example, one insurer’s Medicare Advantage plan may require a referral for specialist care, while a competitor’s plan may not.
Additional benefits, such as Part D coverage or dental and vision care, are also dependent on the company you choose when purchasing your plan.
When Are You Eligible to Enroll?
You are eligible to sign up for a Medicare Advantage plan during your Medicare Initial Enrollment Period, or IEP. Your IEP begins when you turn 65 years old or when you first become eligible for Medicare.
A Special Enrollment Period, or SEP, also provides you the opportunity to purchase a Medicare Advantage plan. SEPs are triggered during certain life events, such as moving or receiving care in a skilled nursing or long-term care facility.
Changes to your Medicare coverage may also be made during Open Enrollment. Medicare Open Enrollment takes place between October 15 and December 7 each year. During Open Enrollment, you may make changes to your Medicare Advantage plan, including finding a plan that offers Part D drug coverage (or dropping one that does). You may also revert to Original Medicare.
From January 1 to March 31, you are permitted to switch Medicare Advantage plans, pick up or drop Part D drug coverage, or return to Original Medicare. You are not, however, allowed to purchase Medicare Advantage unless you are already covered by a Medicare Advantage plan.
You must also live in a given plan’s service area to qualify for coverage.
In most cases, you will not qualify for Medicare Part C coverage if you have end-stage renal disease, or ESRD.
Does Medicare Advantage Provide Coverage for Preventative Healthcare?
While Original Medicare provides coverage for preventative healthcare services, some people may want a more encompassing solution. With Medicare Advantage, you’ll get everything that’s typically covered by Original Medicare Part B. Most Medicare Part C plans provide coverage for additional preventative healthcare such as eye, vision, dental care, lifestyle coaching, and wellness programs.
Medicare Advantage vs. Medigap Plan C and Original Medicare
Medicare Advantage differs from Medicare Supplement Insurance, or Medigap. Medigap is a different type of healthcare insurance that offers standardized plans to supplement Original Medicare. Medigap plans are assigned letters and cover most out-of-pocket expenses in exchange for a premium.
These letter designations can make it difficult to differentiate between different plans. For example, Medicare Advantage is often referred to as Medicare Part C but can be easily confused with Medigap Plan C. Despite having similar names, Medicare Part C and Medigap Plan C differ in many ways.
Medicare Part C is Medicare Advantage, which fully replaces Medicare Parts A and B. In contrast, Medigap Plan C is a Medicare Supplement. Those covered by Medigap Plan C must continue to pay for Medicare Parts A (if applicable), B, and D, as well as the premium for Medigap insurance. With Medicare Advantage, you must only pay the Medicare Part B premium, as well as the Medicare Advantage plan’s premium.
For some, Medicare Advantage plans serve as a more budget-friendly option compared to Medigap. On average, monthly Medicare Advantage premiums cost $231, though many plans have premiums as low as $0 per month. However, you will still be responsible for some cost-sharing and out-of-pocket expenses, such as a deductible, copay, and coinsurance. Still, total out-of-pocket costs are limited by your Medicare Advantage plan.2
In contrast, the premium for the most popular Medigap plans averages between $150 to $186.3 Though Medigap’s premium may be more expensive than a Medicare Advantage plan, Medigap pays for most of the out-of-pocket expenses you would otherwise be responsible for. However, Medigap doesn’t generally offer coverage as comprehensive as Medicare Advantage, leaving you solely responsible for the costs of vision, hearing, and dental care.
While the Medicare Advantage premium may be more affordable on a monthly basis compared to the Medigap premium, Medicare Advantage’s out-of-pocket expenses can result in added and unexpected costs if you become ill or require frequent doctor visits or treatments. This could, theoretically, increase the costs of your healthcare beyond what you would spend on Medigap, which would cover many of your out-of-pocket expenses.
The choice between both types of policies depends on your specific needs and budget. If you want a comprehensive plan with a nominal or non-existent premium and the potential for unexpected out-of-pocket expenses, a Medicare Advantage plan may be a solid option for you. If, however, you need less comprehensive coverage but fewer out-of-pocket expenses for the trade-off of a higher premium, Medigap is a viable option.
There is no cap for out-of-pocket costs, such as copays and coinsurance, if you are covered only by Original Medicare.
Those covered by Medicare Part C may be required to visit in-network providers for non-emergency healthcare. Medigap insurance and Original Medicare only requires that your provider accepts Medicare. Those providers that don’t accept Medigap or Original Medicare assignment may charge you excess charges of up to 15 percent of the total cost of treatment even if you’re already paying for Medigap coverage (although some Medigap plans cover the cost of excess charges). Doctors and providers in a Medicare Advantage plan must participate in the Medicare program, so you won’t be subject to excess charges for visiting a doctor in your plan’s network.
Types of Medicare Advantage Plans
When shopping around for a Medicare Advantage plan, you may be given a choice between different types of plans. Two of the most common types of Medicare Advantage plans are Health Maintenance Organization plans, or HMOs, and Preferred Provider Organization plans, or PPOs.
Health Maintenance Organizations (HMOs)
Medicare Advantage HMO plans require you to receive care from a network of providers and specialists. You may be required to choose a primary care physician who helps coordinate your overall healthcare. You may also be required to obtain a referral before seeing any specialists.
Some HMOs will allow you to visit out-of-network providers for an additional fee, while others will require you to pay the full cost of non-emergency care. In all cases, HMO plans cover emergency care, out-of-area urgent care, and out-of-area dialysis.
If your doctor leaves the plan, you will be allowed to choose another in-network doctor.
Preferred Provider Organizations (PPOs)
Medicare Advantage PPO plans allow you to visit both in-network and out-of-network healthcare providers. However, you may have to pay higher out-of-pocket costs for seeing providers not covered by your plan’s network.
As a result, you won’t require a referral to see a specialist, and you’ll have the flexibility to receive care from any provider of your choice. You are also not required to choose a primary care physician. However, your costs will be lower when seeing doctors and specialists included in your plan’s network.
Other types of plans
Other types of Medicare Advantage plans include:
- Private Fee-for-Service, or PFFS, plans allow you to be treated by any physician or facility that accepts the terms and conditions of the plan and payment with no balance billing.
- Special Needs Plans, or SNP, provide Medicare Part C coverage to groups of people with specific diseases or conditions, such as ESRD; those who are confined to institutions, such as nursing homes; or those eligible for both Medicare and Medicaid.
- Medical Savings Account, or MSA, plans, deposit money from Medicare into a savings account. This money can be used to pay for your healthcare expenses and counts toward the plan’s high deductible.
What Happens If Your Plan Stops Participating in Medicare?
Medicare Advantage plans may opt out of the Medicare program at the end of the year. In the event this happens, your insurer will inform you ahead of time. You won’t be disenrolled from the Medicare program and will instead remain covered by Original Medicare. You will also be permitted to join another Medicare Advantage plan or purchase a Medicare Supplement policy.
How Much Does Medicare Advantage Cost?
The cost of Medicare Advantage is not standardized. Instead, prices are dictated by each specific insurer depending on the type of plan offered and area of coverage. Your premiums may differ from coverage area to coverage area and insurer to insurer. Before choosing a Medicare Advantage plan, be sure to review its coverage levels, out-of-pocket limits, and premiums to find a plan that suits your needs and budget.