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Ashford Insurance

Hurst Medicare Advantage

Medicare Advantage Made Easy

Choosing Between Traditional Medicare and Hurst Medicare Advantage

Choosing between traditional Medicare and Medicare Advantage can be a difficult decision. There are many factors to consider, including your health needs, budget, and lifestyle.

Here are some things to think about when making your decision:

  • Your health needs. If you have any chronic health conditions, you will want to make sure that your plan covers the care you need. Medicare Advantage plans typically have more comprehensive coverage than traditional Medicare, but they may also have more restrictions on your choice of doctors and hospitals.
  • Your budget. Medicare Advantage plans can vary in price, so you will want to find a plan that fits your budget. Medicare Advantage plans typically have lower monthly premiums than traditional Medicare, but they may also have higher copayments and deductibles.
  • Your location. Some Medicare Advantage plans are only available in certain areas, so you will want to make sure that the plan you choose is available in your area.
  • Your lifestyle. If you travel a lot, you will want to make sure that your plan covers out-of-network care. Medicare Advantage plans typically have more limited coverage for out-of-network care than traditional Medicare.

It is also important to remember that you can always change your Medicare plan if you are not happy with it. You can switch plans during the Annual Enrollment Period, which runs from October 15 to December 7 each year. You can also switch plans if you have a qualifying event, such as moving to a new area or losing your job-based health insurance.

Here are some of the pros and cons of traditional Medicare and Medicare Advantage:

Traditional Medicare

Pros:

  • You have more flexibility in choosing doctors and hospitals.
  • You can see any doctor who accepts Medicare, regardless of whether they are in your plan’s network.
  • You have more choices when it comes to prescription drug coverage.

Cons:

  • You may have to pay higher copayments and deductibles.
  • You may have to pay for some services out-of-pocket.
  • You may not have coverage for some preventive care services.

Medicare Advantage

Pros:

  • You may have lower monthly premiums.
  • You may have lower copayments and deductibles.
  • You may have more comprehensive coverage, including coverage for preventive care services.
  • You may have access to additional benefits, such as dental, vision, and hearing coverage.

Cons:

  • You may have less flexibility in choosing doctors and hospitals.
  • You may have to see doctors who are in your plan’s network.
  • You may have to pay a penalty if you leave your Medicare Advantage plan and switch to traditional Medicare.

Ultimately, the best way to choose between traditional Medicare and Medicare Advantage is to talk to your doctor and other healthcare providers. They can help you understand your options and make the best decision for your individual needs.

Understanding the Parts of Medicare

Before discussing the differences between traditional Medicare and Medicare Advantage, it is important to understand the different parts of Medicare and how they work together. Medicare has four parts: Part A, Part B, Part C, and Part D.

Part A covers hospital care (hospital care, skilled nursing facility care, home health care, and hospice care)

Part B covers medical insurance (e.g. doctor visits, medical equipment, outpatient procedures, home health care, lab tests, x-rays, ambulance services, and some preventive services).
Part C, also known as Medicare Advantage (MA) plans, are administered by private insurers that have contracts with the Medicare program. MA is a different way of getting Medicare Part A and Part B coverage The plans combine Part A and Part B, and often Part D, into one plan so the entire package of benefits comes from a private insurance company, regulated by the federal government

Part D provides outpatient prescription drug coverage. Part D is administered and run by private insurance companies that have contracts with the federal government. Individuals who have traditional Medicare, or a Medicare Advantage plan that does not include prescription drug coverage, and who want Part D coverage, must purchase it separately. This is called a “stand-alone” Prescription Drug Plan (PDP). A Medicare Advantage plan that includes both health and drug coverage is referred to as a Medicare Advantage Prescription Drug (MA-PD) Plan.

Key Differences between Traditional Medicare and a Medicare Advantage Plan

It is important to understand some of the key differences between traditional Medicare and Medicare Advantage including enrollment, access to services, costs, benefits, and the appeals process.

If you meet the requirement of at least 40 quarters of employment paying into Social Security, you automatically qualify for Medicare Part A, with no required monthly premium. You should contact Social Security online or in your community to enroll. When you enroll in Medicare for the first time you are automatically enrolled in traditional Medicare, but you can choose a private Medicare Advantage plan if you prefer.

Medicare Part B requires the payment of a monthly premium. You must elect to either accept or decline this coverage, but be aware that there may be penalties for not enrolling during your initial enrollment period. For more details, see our Eligibility and Enrollment page.

In general, you must specifically opt to receive your Medicare coverage through an MA plan; it does not happen without your authorization, except for certain individuals enrolled in certain Special Needs Plans, a type of MA plan. You must be enrolled in Medicare Parts A and B to be eligible to enroll in a MA plan. Note that if you choose to enroll in a Medicare Advantage plan you are still in the Medicare program and you still have Medicare rights and protections but you have chosen to have your Medicare benefit provided through a private plan.

If you are enrolled in traditional Medicare you can go to any doctor or hospital in the United States that accepts Medicare. Traditional Medicare does not have a “network.” Referrals are not needed to see specialists and there is no prior authorization required to obtain services.

If you are enrolled in a Medicare Advantage plan you may be limited by the MA plan to using a network of specific providers for the plan to cover your care. You may have to choose a primary care physician, obtain referrals to see specialists, and get prior authorization for certain services. Certain MA plans may cover care you get outside of the network, but you will likely have to pay more. Most plans may only cover emergency and urgent care if you are out of the service area; you must return to the service area for follow-up or routine care. Network providers can join or leave a plan’s provider network anytime during the year but, generally, you must wait until the next year’s open enrollment period to opt to leave the plan. The MA plan can also change the providers in the network at anytime during the year.

In traditional Medicare, Part A is free if you have worked and paid Social Security taxes for at least 40 calendar quarters (10 years). If you are in traditional Medicare you owe a monthly premium for Part B coverage. You may also have to pay for deductibles, coinsurance, and copays. Traditional Medicare has no out-of-pocket maximum or cap on what you may spend on health care. With traditional Medicare, you will have to purchase Part D drug coverage and a Medigap plan separately (if you choose to purchase one).

Costs in MA plans vary. You must pay the same monthly premium as those enrolled in traditional Medicare Part B. Additional out-of-pocket costs in an MA plan depend on what type of MA plan you choose and may include the following: whether the plan charges an extra monthly premium; whether the plan has a yearly deductible; how much you pay for each visit or service (copayments or coinsurance); the type of health care services needed and how often; and, whether network providers are used.

MA plans may charge cost-sharing for a service that is above or below the traditional Medicare cost-sharing for that service. However, MA plans cannot impose cost-sharing for chemotherapy administration services, renal dialysis services, and skilled nursing care services that exceed the cost-sharing for those services under traditional Medicare. All MA plans must have a maximum allowable out-of-pocket (MOOP) limit on the amount of cost-sharing they can charge for all Part A and Part B services, after which you will pay nothing for covered benefits for the rest of the year. MA plans may also change benefits, premiums, and copays every year.

Traditional Medicare has a standard benefits package that covers medically necessary healthcare services. Traditional Medicare does not offer coverage for prescription drugs. In traditional Medicare, you may have to buy a Medigap plan as well as a separate Part D prescription drug plan.

MA plans must offer a benefits package that is at least equal to traditional Medicare and covers everything traditional Medicare covers. Some MA plans may cover services that are not covered by traditional Medicare such as dental, hearing and vision care, and health club memberships. Many MA plans have prescription drug coverage built into the benefits package.

Regardless of how you receive your Medicare benefits you always have the right to appeal unfavorable decisions regarding coverage of your services. However, timeframes and deadlines differ depending on whether you have traditional Medicare or a Medicare Advantage plan.

What to Do and What to Ask Before Choosing Between Traditional Medicare and a Medicare Advantage Plan

  • Understand how the MA plan you are considering works with any current coverage you may have. If you have retiree or employer health coverage you may lose this coverage if you join a MA plan; alternatively, your former employer may offer you retiree coverage through one or more MA plans.
  • Compare the coverage and costs available through the traditional Medicare program combined with an appropriate Medigap policy and prescription drug plan, versus the available MA plans including any monthly premium, deductible, copayments, and yearly out-of-pocket maximum.
  • Inquire with MA plans as to whether and to what extent you are required to receive services from medical providers who participate in the MA plan you are considering.
  • Be sure the physicians and health care providers you are likely to want to use contract with the MA plan.
  • Ask the MA plans whether there is coverage if you travel outside of the service area.
  • Read the MA plan’s literature to see what kind of plan it is and what it pays for.
  • Not all MA plans, even if the plans are the same type, and from the same insurer, work the same way.
  • Check to see if the medications you need are on the MA plan’s formulary.
  • Determine what MA plan services are provided at what additional cost. All preventive services and extra benefits should be identified, as well as any limitations associated with visits or services. Determine where you are required to go for regular, non-urgent care.
  • Check into the MA plan’s physicians to determine if your physicians are in the plan’s network. If your doctor is in the network then ask your doctor what their experience has been dealing with that plan and whether they would recommend joining the plan. In addition, ask which hospitals, skilled nursing facilities, and home care agencies the plan contracts with to ensure that there are satisfactory choices.
  • Learn how to use the plan’s complaint system and how appeals and grievances are handled.
  • Ask an MA plan representative if member satisfaction surveys are conducted and if the results are available for review.
  • Contact the CMS Regional Office to determine if a plan has failed to comply with CMS regulations.

Other Considerations Between Original Medicare or Hurst Medicare Advantage

Some aspects of your care will be constant whichever plan you choose. Under both choices, any preexisting conditions you have will be covered and you’ll also be able to get coverage for prescription drugs.

But there are significant differences in the way you’ll use Medicare depending on whether you pick Original Medicare or Medicare Advantage. Here’s a comparison of how each works.

Going to the doctor

Under original Medicare, you can choose any providers — primary care doctors and specialists — who accept Medicare. You don’t need referrals to see any medical provider and you don’t have to worry about your doctor leaving a plan’s network. According to the Kaiser Family Foundation, 93 percent of primary physicians participate in Medicare. That means chances are pretty good that any doctor you are currently seeing will accept Medicare and you won’t have to change providers. But be aware that if you are looking for a new physician, 30 percent of primary care doctors aren’t taking new Medicare patients, so you’ll want to ask about that.

Under Medicare Advantage, you will essentially be joining a private insurance plan like you probably had through your employer. The most common ones are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Medicare Advantage employs managed care plans and, in most cases, you would have a primary care physician who would direct your care, meaning you would need a referral to a specialist. HMOs tend to have more restrictive choices of medical providers than PPOs.

Covered care

While Medicare will cover most of your medical needs, there are some things the program typically doesn’t pay for -— like cosmetic surgery or routine dental, vision, and hearing care. But there are also differences between what services you get help paying for.

Under original Medicare, you can get a wide variety of medical services including hospitalizations; doctor visits; diagnostic tests, such as X-rays and other scans; blood work; and outpatient surgery.

Under Medicare Advantage, you will get all the services you are eligible for under original Medicare. In addition, some MA plans offer care not covered by the original option. These include some dental, vision, and hearing care. Some MA plans also provide coverage for gym memberships. And in the past few years, the federal government has been adding services these plans can offer, including such home improvements as wheelchair ramps to help Medicare beneficiaries remain at home, providing transportation to doctors’ offices, and getting meals delivered. Which services are available varies by plan.

Costs

Under original Medicare, the federal government sets the premiums, deductibles, and coinsurance amounts for Part A (hospitalizations) and Part B (physician and outpatient services). For example, under Part B, beneficiaries are responsible for 20 percent of a doctor visit or lab test bill. The government also sets maximum deductible rates for the Part D prescription drug program, although premiums and copays vary by plan. Many beneficiaries who elect original Medicare also purchase a supplemental – or Medigap – policy to help defray many out-of-pocket costs, which Medicare officials estimate could run in the thousands of dollars each year. There is no annual cap on out-of-pocket costs.

Under Medicare Advantage, enrollees must still pay the government-set annual Part B premium and sometimes an additional premium for the MA plan. But instead of paying the 20 percent coinsurance amount for doctor visits and other Part B services, most MA plans have set copay amounts for a physician visit, and typically that means lower out-of-pocket costs than original Medicare. MA plans also have an annual cap on out-of-pocket expenses.

You should also check if you are eligible for Medicaid or any of the other assistance programs Medicare offers to low-income enrollees.

To help you get an idea of what your out-of-pocket costs would be, you can consult the Centers for Medicare & Medicaid Services’ out-of-pocket cost calculator, which can help you compare your estimated out-of-pocket expenses.

Logistics

Under original Medicare, to get the full array of services you will likely have to enroll in four separate elements: Part A; Part B; a Part D prescription drug program; and a supplemental or Medigap policy. Physicians and hospitals have to file claims for each service with Medicare that you’ll have to review.

Medicare Advantage is a one-stop-shopping program that combines Part A and Part B into one plan. In addition, about 90 percent of MA plans also include prescription drugs, which means you wouldn’t have to enroll in a separate Part D plan. There are no Medigap policies for Advantage plans. You do want to be careful to make sure all your doctors are in the plan’s network, though that could change over time.

Where you live

Under original Medicare, you can access care anywhere in the United States as long as the provider accepts Medicare.

Medicare Advantage plans are based around networks of providers that are usually self-contained in a specific geographic area. So, if you travel a lot or have a vacation home where you spend a lot of time, your care may not be covered if you go to out-of-network providers, or you would have to pay more for care. In addition, while MA plans are pretty much available throughout the United States, the choice of plans is more limited in rural areas.