The main advantage of Medicare Advantage plans is that they limit the amount of money you have to pay out of your own pocket for health care. Medicare Advantage is Part C of Medicare and it is provided by private insurance companies. While Medigap is a supplement to original Medicare, Medicare Advantage is more like a replacement. Part C plans must provide at least what Original Medicare would provide in terms of benefits. Generally, Part C: Medicare Advantage Plans will include additional benefits such as prescription drugs, dental care, vision care, annual physicals, coverage outside the US, and even reduce the 20% co-pays and high deductibles associated with Original Medicare.
Once you’ve reached the maximum, most Part C plans prohibit providers from mixing in additional separate charges—sometimes called “balance billing”—that they send to you directly. This prohibition applies even if the plan pays a provider less than the provider charges for a service or if there’s some other dispute between the plan and the provider. Another important note: To qualify for some Part C plans you must be entitled to Medicare Part A and enrolled in Part B. Usually, the Part C plan administrator will help you make sure this “paperwork” is in order—but it’s important that you realize rules may require you to enroll in Part B even if you’re using a Part C plan. If you choose a Part C plan, you will need to choose a network primary care provider (PCP) who oversees and coordinates your care.
Medicare Advantage Plans will usually cost an additional monthly premium in addition to your Part B premium. The trade-off for all these benefits is the area of service a Medicare Advantage Plan covers. Original Medicare is accepted by any doctor that accepts Medicare (nationwide) but Medicare Advantage is limited to a provider network. Medicare Advantage plans are usually HMOs or PPOs though there are PFFS and SNPs.
- Health Maintenance Organizations (HMO) are health insurance policies that require a primary care physician and they act as the hub that links you to other doctors within the provider network.
- Preferred Provider Organizations (PPO) are more flexible than HMOs and allow you to see doctors as you please but doctors within the provider network will be significantly cheaper.
- Private Fee-for-Service (PFFS) plans are provided by private insurance companies. Like Medicare, PFFS plans are pay for service plans but PFFS plans would have a regional network while Medicare is nation-wide.
- Specialty Needs Plans (SNPs) are provided by private insurance companies but SNPs limit memberships to those with specific diseases or characteristics. As such, these plans can be specifically tailored to a more focused group of individuals.
It is important to know which providers are in your plan’s network because, with a few exceptions, you must use network providers to get your medical care and services. (The exceptions are emergencies, urgently needed care when the network is not available.)
When can I enroll for a Medicare Advantage plan?
Medicare Advantage has 3 times to sign up:
- Initial Enrollment Period when you first become eligible for Medicare or when you turn 65. This is a 7-month period which includes the 3 months before the month you turn 65, the month you turn 65, and the 3 months following.
- Medicare Open Enrollment Period which is from October 15 - December 7 every year.
- Special Enrollment Periods when certain events, such as moving to a new service region, cause you to lose coverage or gain additional benefits.