When someone becomes eligible for Medicare, usually at age 65, the newly qualified person can enroll in Medicare and choose to have coverage under a couple of options. The first option is to get the Original Medicare Plan and add one or more Supplemental Insurance Plans to cover the gaps in coverage such as deductibles, and other medical costs not covered by Original Medicare. The other option is to choose a Medicare Advantage Plan.
Use the form above to shop around for the best plan.
In a Medicare Advantage Plan (private health plan) you generally must pay the Medicare Part B premium. Some Medicare Advantage Plans may also charge you an additional premium. In some cases, the plan may pay part of your Part B premium. Medicare Advantage Plans may have a deductible for hospital visits, doctor visits, or prescription drugs, but some do not. Plans usually charge you a fixed co-payment when you visit a doctor, instead of the 20% coinsurance you pay under Original Medicare.
All plans must include a limit on the amount of money you spend out-of-pocket during the year. In 2018, the maximum out-of-pocket limit for most plans is $6,700. They also cannot charge higher copayments than Original Medicare for certain care. This includes chemotherapy, dialysis, and skilled nursing facility (SNF) care. They can charge you more than Original Medicare for other services such as home health, durable medical equipment, and inpatient hospital services. Many Medicare Advantage Plans have a network of doctors, hospitals, and pharmacies, and provide services only in a specific part of the country. Be sure to always review the plan’s cost and coverage before enrolling!
Medicare Advantage Plans, sometimes also referred to as Part C, or Medicare private plans operate through contracts with the federal government. Providers are paid a fixed per person amount to provide Medicare benefits. All plans must provide Part A and Part B services in the same level offered by Original Medicare. However, different carriers may do so with different costs, rules and restrictions which will impact how and when the enrollee may receive care.
Medicare Advantage Plans are offered in a variety of forms. The most common form of MA plans is by way of an HMO (Health Maintenance Organization) which has made up the clear majority of enrollments in the past and is projected to be the overwhelming majority of enrollments in the coming Medicare Advantage 2020 year. Among the pros of HMOs is that they often have zero deductibles and zero co-payments. Enrollees choose a primary care physician who directs all their medical care. HMO plans usually require that members get a referral to see any specialist care providers and also need to obtain an authorization for selected procedures or diagnostic tests.
HMOs provide care through a closed network of providers which means that all but emergency medical care must be provided within the network if you expect to have it paid by the plan.
The second option for MA plans is a PPO plan – (Preferred Provider Organization) Under this structure of care; the plans also make use of provider networks; however, you are free to use any medical service provider who accepts Medicare. You can keep your out-of-pocket expenses low if you stay within the approved/preferred provider network. Under a PPO, you do not have to choose a Primary Care Physician.
Both HMOs and PPOs usually include drug coverage which is Medicare Part D.
Medical Advantage Plans which are the Private Insurance Option of Original Medicare or Part C, are offered through a network of private companies that are approved by Medicare. If you weigh your options of Original Medicare, Original Medicare with Medigap Plans or Medical Advantage plans and decide that an MA plan is for you, the next step will be to shop for the right plan.
Before you enroll in a Part C plan though, you need to enroll in both Parts A and Part B of Original Medicare. Once you have done that, you can then enroll directly with the MA plan of your choosing through any authorized private insurer.
There are quite a few differentiating elements of Original Medicare and Medicare Advantage Plans. Before we look at the differences though, let’s quickly review the areas in which they are similar. All qualified Medicare Advantage Plans are required to provide at the minimum, the same coverage as Original Medicare Parts A and B. You are then assured that with either option, you will have your essentials covered.
Where Medicare Advantage Plans differ and have the edge over Original Medicare is in the fact that they (MA Plans) offer by far more benefits/coverage than Original Medicare. The following are important areas in which MA plans offer you more than the Original Medicare option:
Coverage: Under Original Medicare part A covers medical and part B covers hospital costs only. Medicare Advantage plans offer, in addition to medical and hospital costs, dental insurance, prescription drugs, hearing and vision coverage.
Costs: Original Medicare only pays for a stipulated number of days in a skilled nursing facility or hospital, and there is no cap on what you pay out-of-pocket. MA Plans have a cap on how much out of pocket you will spend each year. Once you have met that maximum, the plan will usually pay one hundred percent of the cost for covered services. For seniors, this is a big deal.
Travel: Original Medicare does not offer coverage outside of the country, even if it is an emergency. MA plans may cover you if you travel outside the country. There are typically stipulations and lifetime maximums.
Copay Vs. Coinsurance: Original Medicare covers the first eighty percent of the cost, you are then responsible for the remaining twenty percent of the bill for things like doctor office visits, outpatient surgery and other basic medical services. Your out-of-pocket will vary based on the total bill. With a Medial Advantage Plan – you pay a copayment which is fixed.
Network – With Original Medicare you have the choice of any provider or facility which accepts Medicare. You have a lot of options. Medical Advantage plans, as we covered previously and depending on the type of plan you choose, will usually have a closed network or a preferred network of providers. You can of course, still go outside the network, you will just have to be responsible for 100% of the bill in most cases.
Each year from January 1st – February 14th, people over 65 can make specific changes to their Medicare Plan. You can only change plans if you have a private Medicare Health Plan. It is important to note that under Federal Law, if you disenroll from a Medicare Advantage Plan, that does not entitle you to enroll in a Medigap Plan. State laws vary however, and they may offer you additional rights including the right to enroll in a Medigap plan. Before you make any changes, make sure to contact the State Health Insurance Assistance Program (SHIP) at 800-MEDICARE.
Here is what you can do in most cases under Federal Law:
If you have a MAPD (Medical Advantage Plan with prescription drug coverage), you can switch to Original Medicare with OR without a prescription drug plan.
If you have a Medicare PFFS (Private Fee For Service) plan which does not offer prescription drug coverage and a stand-alone prescription drug plan, you switch to Original Medicare. However, you will need to keep your current prescription drug plan.
If you are enrolled in Original Medicare or Original Medicare with a prescription drug plan (PDP), you are not allowed to change plans at this time.
This is one of the most frequently asked questions as you can imagine. The number of options under each plan can be overwhelming and there is no easy answer. Here are some fundamentals that you can help you evaluate the pros and cons of each. For more indepth information, see our page Medicare Advantage vs Medigap.
Under Original Medicare with the add-ons of Medigap plans – you have to carefully review and understand the coverage of Original Medicare and then “Plug the holes” with Medigap plans. With a Medicare Advantage Plan, you are likely to get better, more comprehensive coverage than with Original Medicare and Medigap plans stitched together. MA plans encompass all parts of Original Medicare, and fill the gaps that you would normally need to buy Medigap plans to cover. In addition, MA plans by some carriers offer zero plan premiums, zero copayments and no deductibles, all under one plan. There are advantages in simplicity.
Medicare Advantage 2020 enrollment will be coming up soon. Being fully informed is the first step in knowing your options. Make sure to consult with a Licensed Insurance Agent to be guided in finding the best plan for you.