Medicare Advantage Plans

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Medicare Advantage plans must provide the Medicare-covered services available through Part A and Part B, but each plan can structure its costs and additional benefits differently. 

Depending on the specific plan, benefits may include:

• Medical coverage for hospital and physician services covered by Medicare
• Prescription drug coverage with many Medicare Advantage plans
• Dental, vision and hearing benefits
• Fitness or wellness benefits
• Over-the-counter (OTC) benefits
• Transportation or other supplemental benefits on certain plans
• Special supplemental benefits for qualifying members with chronic conditions on certain plans
• A yearly maximum out-of-pocket limit for covered medical services

Unlike Original Medicare, Medicare Advantage plans have an annual limit on the amount you pay out of pocket for covered Part A and Part B services. Once you reach your plan's limit, the plan pays 100% of covered health services for the remainder of the year.

Two of the most common types of Medicare Advantage plans are HMOs and PPOs.

HMO (Health Maintenance Organization) plans generally require you to receive non-emergency care from providers within the plan's network. Depending on the plan, you may also need a referral before seeing certain specialists.

PPO (Preferred Provider Organization) plans generally provide more flexibility to receive care outside the plan's network, although you may pay more when using out-of-network providers.

Other types of Medicare Advantage plans are available as well, including Special Needs Plans (SNPs) designed for certain groups of Medicare beneficiaries. 

There isn't one Medicare Advantage plan that's best for everyone. A plan that works great for your neighbor, spouse, or friend may not be the best choice for you.

When we help someone compare Medicare Advantage plans, we look beyond the monthly premium. Some of the most important questions include:

Are your doctors in network?
Changing plans could affect which doctors, specialists, hospitals, and other providers you can use.

Are your prescriptions covered?
Drug formularies, tiers, deductibles, copays, and pharmacy networks can vary considerably from one plan to another.

What will you pay when you use your coverage?
It's important to consider copays and coinsurance for services such as specialists, outpatient surgery, diagnostic testing, hospital stays, and other medical care—not just the monthly premium.

What is the maximum out-of-pocket amount?
Understanding your potential costs in a year when you need significant medical care can be just as important as looking at your everyday copays.

Which additional benefits are actually valuable to you?
Dental, vision, hearing, OTC, fitness and other supplemental benefits can be helpful, but they shouldn't distract from making sure your doctors, medications and healthcare needs are covered appropriately.

Medicare also notes that Medicare Advantage plans may have provider-network requirements and may require prior authorization for certain services or medications.

You may see Medicare Advantage plans advertised with a $0 monthly plan premium. That doesn't mean all of your healthcare will be free.

You generally must continue paying your Medicare Part B premium, and your Medicare Advantage plan may have deductibles, copays or coinsurance when you receive medical care. Costs vary by plan. 

That's why we believe it's important to look at the whole plan, rather than choosing a plan based on one benefit or its monthly premium.

Medicare Advantage benefits aren't necessarily the same from one year to the next. Premiums, copays, provider networks, prescription formularies, supplemental benefits and other plan details can change.

We encourage our clients to review their coverage each year to make sure their current plan continues to fit their needs.