What is Medicare Advantage?

This is a question we hear hundreds of times each year at Ashford Insurance. Here are the basics:

Medicare Advantage Explained

Members get their care from a network of doctors and hospitals.

A Medicare Advantage plan is a private health insurance plan that you may opt to get your benefits from instead of traditional Medicare. Originally called Part C, Advantage plans usually have an HMO or PPO network of doctors and providers.

By joining one of these plans, you direct Medicare to pay the plan a set monthly amount for your care. In return, the plan will deliver all your Part A & Part B (and sometimes D) services. You must continue to pay your Medicare Part B premium while enrolled in an Advantage plan.

Medicare Advantage is NOT a Medicare Supplement (Medigap) plan. They work completely differently, and you cannot have both at the same time.

Medicare Advantage Coverage

When enrolled in an Advantage plan, you will pay co-payments when you receive healthcare services. Each plan sets its own cost-sharing. For example, you might pay a co-pay for a primary care doctor’s visit, and a higher co-pay for a specialist visit. Similarly, some plans will charge you a daily hospital co-pay, and other plans might charge a flat amount for the whole stay.

Limitations, copayments, and restrictions might apply, and each plan’s benefits, formulary, pharmacy network provider network, premium, and copayments may change on January 1 of each year. Members need to be diligent about reviewing the plan materials, especially the Annual Notice of Change, sent to them each year in September to see what’s changing.

All Medicare Advantage plans must include an out-of-pocket maximum cap on your medical spending, not including Part D expenses which are calculated separately. The highest cap allowed by Medicare can change each year, although some plans may be lower. This is a built-in safety net. If you have heavy health spending resulting in you spending the full out-of-pocket maximum in a calendar year, then the plan kicks in and pays the rest for the balance of the calendar year.

These plans also frequently include small extras that original Medicare doesn’t cover. Some common examples would be vision and dental benefits, hearing discounts, and health and wellness programs, such as gym memberships. These benefits also may change from year to year.

Another popular feature of Advantage plans is that they often include a built-in Medicare Part D drug plan, which saves you from having to purchase one separately.

Part C Advantage plans have different networks, premiums, and cost-sharing. Working with an insurance agency that specializes in these plans is a wonderful way to ensure that you consider all the variables before choosing your insurance company. Get help from Ashford Insurances Medicare insurance experts at 817-952-3153!