Understand Differences Between Medicare and Advantage Plans

Understanding Medicare health insurance plan options can be daunting for Medicare beneficiaries. Most individuals qualify for Medicare at age 65 and may be automatically signed up if they’re already receiving Social Security. Original Medicare comes in two parts: Part A and Part B. Part A covers a portion of hospitalization expenses, and Part B applies to doctor bills and other medical expenses, like lab tests and some preventive screenings.

Medicare Advantage, also known as Medicare Part C, makes it possible for people with Medicare Part A (hospital insurance) and Part B (medical insurance) to receive their Medicare benefits in an alternate way. Medicare Advantage plans are offered through private insurance companies that are contracted with Medicare and provide at a minimum the same level of coverage that Medicare Part A and Part B provide.

You may be trying to decide which is better: sign up for a Medicare Advantage plan or just stick with Original Medicare. There isn’t a simple answer because most Medicare Advantage plans have attractive features that many people find beneficial and other characteristics that may not match your personal lifestyle or preferences. Just what are some of the important pros and cons of Medicare Advantage plans.

Medicare Advantage plans

These plans are run by private insurance companies and are regulated by the government.
Medicare Advantage plans often provide more benefits than you would receive under Original Medicare.
Most Medicare Advantage plans will also include prescription drug coverage, which is an optional add-on called Part D for beneficiaries who just opt for Original Medicare.

Medicare Advantage plans must offer at least the same level of coverage as Medicare Part A and Part B and many plans offer added benefits. These may include coverage for routine vision care, hearing aids, routine dental care, and a fitness center membership.

Medicare Advantage plans may cost you less.

If you enroll in a Medicare Advantage plan, you continue to pay your Medicare Part B premium and you may pay an additional premium. The insurer determines the Medicare Advantage plan’s premium, which can vary from one plan to another. Some Medicare Advantage plans may even have a $0 premium.

Medicare Advantage plans are like individual health insurance policies you may have received through your employer or signed up for on your own through the individual insurance market, in that they have different monthly premiums, provider networks, co-pays, coinsurance, and maximum out-of-pocket limits.

Your cost-sharing may also be less under Medicare Advantage. For example, if you visit a primary care physician under Medicare Advantage, you may pay a co-payment of $10. However, if you visit a primary care physician under Original Medicare, you may have a coinsurance of 20%, which could be more than $10.

Also, a Medicare Advantage plan limits your maximum out-of-pocket expense. Once you have spent that maximum, you pay nothing for covered medical services for the remainder of the year. Original Medicare does not provide a maximum out-of-pocket cap, so your potential expenses are limitless.

Frequently a Medicare Advantage plan can be less expensive than comparable coverage you would receive if you stayed with Original Medicare. To get all the benefits of Medicare Advantage with Original Medicare, you would also need to enroll in a Medicare Supplement plan as well as a stand-alone Medicare Part D Prescription Drug Plan.

Medicare Advantage plans coordinate care among your health care providers.

Typically, Medicare Advantage plans are managed care and have networks of contracted health care providers. An example would be a Health Maintenance Organization (HMO) Medicare Advantage plan. These HMO plans require you to select a Primary Care Physician (PCP) who helps to coordinate your care.

Some Medicare Advantage plans have large inclusive Networks of Doctors, Specialists, Hospitals, and other providers.

Medicare Advantage plans that include prescription drug coverage may also have medication therapy management. This care coordination can be a convenience and a valuable benefit to your health.

Medicare Advantage plans may serve as your “one-stop-shop” center for all your health and prescription drug coverage needs.

Many Medicare Advantage plans coordinate the delivery of added benefits, such as vision, dental, and hearing care. You may prefer the convenience of working with one plan administrator.

Most Medicare Advantage plans have some out of network coverage like emergency and urgent care.

Some Medicare Advantage care plans have small un-inclusive Networks limiting your freedom of choice in health care providers

The trade-off for a lower premium (or $0 premium) is having to pay co-pays or coinsurance which costs vary by plan.

With the federally administered Medicare program, you can go to any doctor or facility that accepts Medicare and receive the same level of Medicare benefits for covered services. In contrast, Medicare Advantage plans are more restricted in terms of their provider networks. If you go out of network, your plan may not cover your medical costs, or your costs may not apply to your out-of-pocket maximum.

Medicare Advantage plans’ coverage for some services and procedures might require a doctor’s referral and plan prior authorization.

Medicare Advantage plans try to prevent the misuse or overuse of health care through various means. This might include prior authorization for hospital stays, home health care, medical equipment, and certain complicated procedures. Medicare Advantage plans often also require your primary care doctor’s referral to see specialists before they pay for services.

Medicare Advantage plans have specific service areas broken down by county.

Most Medicare Advantage plans have regional (rather than nationwide) networks of participating providers. To enroll, you must reside in the Medicare Advantage plan’s service area for at least 6 months of the year. If you divide your time between homes located in different areas, this requirement could be difficult to meet.

The bottom line is that Medicare Advantage plans may provide more affordable coverage than you would receive otherwise. The trade-offs are that you must follow the Medicare Advantage plan’s rules to receive payment for covered services.

Do you have questions about Medicare Advantage plans? Call us and speak with a licensed insurance agent about finding Medicare Advantage plans in your area and your Medicare coverage options.