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If you’ve decided that a Medicare Advantage plan (or another Medicare health plan) is best for you, you’re one of more than 21 million who have made a similar decision, according to the Centers for Medicare and Medicaid Services in 2018.
With Medicare Advantage (Part C) you don’t have to worry that your plan won’t cover something that Original Medicare (Part A and Part B) covers. Medicare Advantage is required to cover everything that Original Medicare covers, which the exception of hospice care, which Part A still covers. When choosing a Medicare Advantage plan you may have many options for plan type, coverage and cost. Keep in mind that not all Medicare Advantage plans are available in all areas.
Medicare Advantage Plan Type
The first thing you may consider when deciding on a Medicare Advantage plan is the plan type. The four most common types of Medicare Advantage plans are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs*), Private Fee-For-Service Plans (PFFs) and Special Needs Plans (SNPs). You may already be familiar with some of these plan types by having a similar plan sponsored through your employer. Determining the Medicare Advantage plan that best fit your health care needs may depend on how you want to access primary care doctors, specialists, and hospitals, and whether or not you have a special circumstance.
- HMO (Health Maintenance Organization): generally requires you to select a primary care doctor and get a referral to see a specialist. You’re generally not covered for services you receive outside the plan’s network of Medicare providers.
- PPO (Preferred Provider Organization): generally allows you to use any doctor or hospital but usually charges you less to use doctors and hospitals in the plan’s network. You generally don’t need a referral to see a specialist so if you want to see a dermatologist, for example, you generally can just make an appointment without consulting your primary care physician.
- PFFS (Private Fee-for-Service)**: like a PPO, you might not need to choose a primary care physician, and you might not need a referral to see a specialist. Just be aware that not all Medicare providers accept the plan’s payment terms.
- SNP: A Special Needs Plan is for people in certain circumstances, such as people in a nursing home or people with a severe or disabling chronic condition. The plan may tailor the benefits to the needs of the people it serves.
Medicare Advantage coverage
Remember that Medicare Advantage plans must provide, at a minimum, all the coverage that Medicare Part A and Part B provide (except for hospice care, which is still covered by Part A). If Medicare Part A and Part B cover a certain vaccine, for example, Medicare Advantage generally must cover it also. Medicare Advantage plans may provide additional coverage for services Medicare Part A and Part B typically don’t cover such as:
Many Medicare Advantage plans cover prescription drugs. Some Medicare Advantage prescription drug plans may have a prescription drug deductible. Most Medicare Advantage prescription drug coverage has different pricing for prescription drugs depending on the category they fall into. These categories could be preferred generic, generic, preferred brand, non-preferred, or specialty. Another category system for Medicare Advantage prescription drugs is tier 1, tier 2, tier 3, tier 4, and tier 5. Cost may also differ for mail-order prescription drugs and standard retail prescription drugs.
Routine dental services
Preventative care may be included in your Medicare Advantage plan, such as exams, cleanings, fillings, tooth extractions and x-rays. Medicare Part A usually only covers emergency or complicated dental procedures.
Other coverage a Medicare Advantage plan may provide that Medicare Part A and Part B usually do not cover:
- Routine hearing services and hearing aids
- Routine eye exams and eyewear
- Fitness programs
Medicare Advantage plan costs
Different Medicare Advantage plans may have different out-of-pocket costs.
One cost for a Medicare Advantage plan is a monthly premium. Some Medicare Advantage plans offer a $0 monthly premium, but with all plans you must continue paying your Medicare Part B premium. Be aware that a Medicare Advantage plan with the lowest premium may not necessarily be the least expensive plan. Consider other costs, such as copays.
Copayment or coinsurance
A copayment is usually a set dollar amount, for example, $45, that you must pay when you receive a specific medical service. Coinsuranceis a different kind of cost-sharing. It’s a percentage (such as 20%) of the total cost of a doctor visit.
Different Medicare Advantage plans may charge different copayments or coinsurance amounts. If you have a PPO plan, the plan may charge you a higher copayment or coinsurance for a visit to a doctor out-of-network. Preventative services may come with a $0 copayment with some Medicare Advantage plans.
Some services you may have to pay a copayment or coinsurance for are (this list may not include every service):
- Emergency room visits
- Ambulance services
- Outpatient surgery
- Outpatient rehabilitation services
- Skilled nursing facility
Some Medicare Advantage plans have deductibles and some do not. A deductible is an amount you must pay-out-pocket for your own health-care expenses before your plan begins to pay.
One benefit of Medicare Advantage over Medicare Part A and Part B is that Medicare Advantage plans typically have annual out-of-pocket maximums. This is a maximum amount that you pay in a year before the plan begins to pay 100% of your health-care costs. If you expect to use medical services a lot, you may want to pay close attention to your plan’s out-of-pocket maximum.
If you have more questions about Medicare Advantage plans, I can help answer your questions. To get started, simply click the Get Quotes button to schedule a phone call or to request a personalized email.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. 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.