Medicare Advantage plans, also called Medicare Part C, are an attractive alternative to Original Medicare for some people. Medicare Advantage gives you all the benefits of Original Medicare, but may provide additional services, such as vision or dental care, and there may be cost advantages as well.
One of the biggest differences in the two types of Medicare is your plan’s administrator. Original Medicare is administered by the government, while Medicare Advantage plans are administered by private insurance companies (although they must be approved by the federal government). Because Medicare Advantage plans are provided by private insurers, you’ll need to compare them to see which one offers you the most benefits for the least cost.
How to Compare Medicare Advantage Plans
Since most companies service a specific area within the U.S., not all Medicare Advantage plans will be found in your own region. To find out what plans are available in your area, Medicare has a website that allows you to find and compare Medicare plans so that you can make an informed decision about the plan that’s best suited for your needs.
If you are nearing your 65th birthday, or have a disability that makes you eligible for Social Security disability benefits, it’s a good idea to take some time to review the plans that are available to you through Medicare. The federal government’s Medicare website is a good first stop, since it allows you to learn more about the various plans available through the Medicare system and compare each provider’s offerings.
Compare Medicare Advantage Plan Benefits
All Medicare Advantage plans are required by law to provide you with all the benefits that you would have with Original Medicare. This includes Part A (hospital and skilled nursing care, hospice, and home health care) and Part B (many outpatient services, as well as ambulance, clinical research, and mental health costs).
Many Medicare Advantage plans also include drug coverage, which is an optional, stand-alone coverage option (called Part D) with Original Medicare. One of the advantages of Medicare Advantage plans is that they bundle these coverages into one comprehensive plan, rather than being split up into separate parts, as they are with Original Medicare.
Depending on the plan, you may also find coverage with your Advantage plan for the following:
- Routine dental and vision care
- Routine hearing care, as well as some of the costs associated with hearing aids
- Gym memberships, including Silver Sneakers coverage
- Coverage for your prescription drugs
Consider Medicare Advantage Plan Costs
Of course you’ll want to consider the costs involved in your Medicare Advantage plan, and how you can get a plan tailored to your specific needs for as little money as possible. There are several types of cost associated with your Medicare Advantage plan, including the following:
- Your monthly premium: This is a cost that you’ll pay each month, just as you would for a regular health insurance policy. Some Medicare Advantage plans don’t include a monthly premium — but don’t assume these will cost you less, as the company may make up for the lack of monthly premium by charging more for other fees. Another factor worth noting: you may continue to have to pay a premium for Medicare Part B even on an Advantage plan, or your insurer may pay part or all of this cost.
- Your annual deductible: This is the amount you must pay in total before your Medicare Advantage plan kicks in. This cost varies from insurer to insurer, and may be in the thousands of dollars.
- Copayment or coinsurance: These costs are what you would pay each time you receive health care services or purchase a prescription drug. Copayments, which are usually a set fee such as $15 or $20, are more common. Coinsurance is similar, but it is a percentage of the actual cost, rather than a set amount, so you might, for example, be required to pay 20% of the total cost of a visit to your doctor.
- Additional costs if you go out-of-network: Many plans require you to use preferred health care providers. If you choose to use a doctor or other health care professional who is not part of the preferred list, you may be required to pay an additional amount.
One benefit of Medicare Advantage plans is that they have a yearly limit for out-of-pocket costs. If you go over this amount, your plan should pay 100% of the costs of covered health care services or items. This maximum amount will vary from plan to plan, and it’s something you should find out before you sign up.
Understand Medicare Advantage Plan Types
Medicare advantage plans fall into several general categories, related to how your health care services are administered. You should be able to choose which type of plan you’d like to enroll in, depending on your needs and on the type of plan that is available in your region.
A Health Maintenance Organization, or HMO, is one of the most common types of Medicare Advantage plan. These plans require you to choose a primary care provider (PCP), who will be in charge of your medical needs. Your PCP will give you recommendations to specialists if needed, and those specialists will need to be part of the company’s network of preferred providers. If you deviate from this network, you may have to pay the full costs of your medical care. HMOs usually include drug coverage.
PPO stands for Preferred Provider Organization, and it’s not that different from an HMO in that you pay less if you use providers that are part of the company’s network of preferred providers. You may, however, go out-of-network if you need to, to see any provider who accepts your plan, but you may pay a bit more. PPOs don’t require a referral for specialist care, and like HMOs, usually have drug coverage.
Private Fee-for-Service plans, or PFFSs, are less common. With these plans, you do not have to choose a PCP, nor do you need to get referrals for specialists. The flip side is that many companies don’t offer this type of plan. PFFS plans may or may not cover drug costs.
A Special Needs Plan (SNP) is a very specific type of plan that covers individuals with specific illnesses or health care needs. Each plan is tailored to provide the care and drug options that are generally associated with that illness. For example, there are plans focused on care for chronic heart failure, HIV/AIDS, dementia, or End-Stage Renal Disease (ESRD). SNPs usually require you to choose a PCP and stick within the provider network, and all of them offer prescription drug coverage.
What to Ask When Comparing Medicare Advantage Plan
Armed with the information from the Medicare website, you may want to ask yourself a few questions:
- What are the costs associated with each plan, including premiums, deductibles, and copays?
- What is the out-of-pocket maximum per year?
- How is this plan rated? (The Medicare site gives each plan a rating, with five stars being the highest. A plan with four or four and a half stars is considered good.)
- What kind of coverage options does each plan offer? (You can purchase plans with or without drug coverage, as well as coverage for things like vision and hearing as well as gym memberships and fitness programs.)
- Do I want an HMO, PPO, PFFS, or SNP plan?
- If a plan has a network of preferred providers, are my usual doctors and other health care professionals on that list?