Medicare Plans for Baby Boomers

Medicare Advantage plans can be full of extra benefits like prescription drug coverage, and dental, hearing, and vision coverage. Another advantage of a Medicare Advantage plan is a mandatory out-of-pocket maximum. You may also be limited to provider networks.

If you’re new to Medicare, you may be curious about Medicare Advantage. Here are some pros and cons of enrolling in a Medicare Advantage plan.

For starters, Medicare Advantage plans are offered by private insurance companies but are regulated by Medicare. Regardless if the Medicare Advantage plan you choose has a monthly premium or not, you must continue to pay your Medicare Part B premium. Some Medicare Advantage plans have premiums as low as $0.

You may not know that Original Medicare (Part A and Part B) has no out-of-pocket maximum. That means that if you face a catastrophic health concern, you may be responsible to pay tens of thousands of dollars out of pocket.

All Medicare Advantage plans have out-of-pocket maximums, which prevent you from very high spending when a serious illness happens. Once you meet this limit, your plan covers the costs for all Medicare-covered services for the rest of the year. In 2022 the out-of-pocket limit is $7,550. Plans can set lower limits, but not higher ones.

Medicare Advantage plans may offer extra benefits beyond what Original Medicare covers. Medicare Advantage plans must cover, at a minimum, everything that Part A and Part B cover. They also may offer extra benefits such as…

 Prescription Drugs

• Most Medicare Advantage plans have prescription drug coverage. This could be good news if you take one or more prescription drugs.

Vision and hearing

• Many Medicare Advantage plans offer routine vision and hearing coverage. This could include coverage for routine eye exams, routine eyewear, routine hearing exams, and hearing aids.

Gym Membership

• Gym membership provides a fitness program for Medicare Advantage beneficiaries. Not all plans offer Gym Membership.

Dental

• Some Medicare Advantage plans may cover preventative dental services including oral exams, cleanings, fluoride treatment, and x-rays.

Other extra perks

• Other extra benefits may include:
• Meal delivery for beneficiaries with chronic illnesses
• Transportation for non-medical needs like grocery shopping
• Carpet shampooing to reduce asthma attacks
• Transport to a doctor’s appointment or to see a nutritionist
• Alternative medicine such as acupuncture
• Keep in mind not all Medicare Advantage plans offer the same extra benefits. Since benefits vary by plan, check with the specific Medicare Advantage plan you’re considering for more details.

Lower out-of-pocket costs

• Under Medicare Advantage, each plan negotiates its rates with providers. You may pay lower deductibles and copayments/coinsurance than you would pay with Original Medicare. Some Medicare Advantage plans have deductibles as low as $0.

ESRD coverage

• Medicare Advantage plans can now accept you if you’re a Medicare beneficiary under age 65 who has ESRD (end-stage renal disease, a type of kidney failure).

Medicare Advantage Cons

Con 1: Networks

Many Medicare Advantage plans have networks, such as HMOs (health maintenance organizations) or PPOs* (preferred provider organizations). Many Medicare Advantage plans may have provider networks that limit the doctors and other providers you can use. Under Original Medicare, you can use any provider that accepts Medicare assignments.

Con 2: Doesn’t work with Medicare Supplement

Medicare Advantage and Medicare Supplement insurance plans are mutually exclusive. Medicare Supplement insurance plans help cover Medicare’s out-of-pocket costs, such as copayments, coinsurance, and deductibles. You can’t get this help if you have a Medicare Advantage plan.

Con 3: The out-of-pocket maximum resets every calendar year

… and it also varies among plans (although no plan may exceed the Medicare-set maximum amount). For example, suppose your plan out-of-pocket maximum is $6,700 per year. Say you start getting cancer treatment in October. You could reach your $6,700 maximum in 3 months. Then as you keep getting treatment in January, you could reach your $6,700 maximum again in three more months. That’s $13,400 out of pocket in six months.

If you decide a Medicare Advantage plan is not for you may consider a Medicare Supplement plan.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergencies. For a decision about whether the plan will cover an out-of-network, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.