Key Points
1. When you enroll in an Advantage plan (Medicare Part C), you agree to receive your Medicare benefits through that private plan instead of through Original Medicare.
2. Advantage plans operate within network areas, some of which can be more strict or lenient, depending on the type of Advantage plan.
3. There are different times to enroll in an Advantage plan throughout the year, including your Initial Enrollment period, the Annual Election period, and more1.
What are Medicare Advantage Plans
Medicare Advantage plans, also known as MA, are NOT similar to Medigap plans – they are different. Members get their benefits from a private insurance company instead of Original Medicare. As we mentioned, sometimes you’ll hear them referred to as Medicare replacement insurance.
Medicare is not really a fan of this language because it’s not entirely accurate. You never permanently replace your Medicare when you join a Medicare plan. Instead, you are just choosing to get your benefits from a private company for the rest of the calendar year. You can always return to Original Medicare during a valid election period.
How Medicare Advantage Plans Work
A Medicare Advantage plan is a private Medicare insurance plan that you may join as an alternative way to get your Part A and Part B benefits. When you do, Medicare pays the plan a fee every month to administer your Part A and B benefits. You must continue to stay enrolled in both Medicare Part A and B while enrolled in your Medicare Advantage plan. Medicare pays the Advantage plan company on your behalf to take on your medical risk. This is how Medicare Advantage plans are funded. You will present your Advantage plan ID card at the time of treatment. Your providers will bill the plan instead of Original Medicare. Again, this is also why some providers consider them Medicare replacement plans, but it’s important to remember that you can always return to Original Medicare during a future annual election period .
Medicare Pays a set amount of money to the Private Insurance Company and they manage your care. You are no longer on Original Medicare
Medicare Advantage Plans
Each Advantage plan has its own summary of benefits. This summary will tell you what your copays will be for various healthcare services. Your plan will offer all the same services as Original Medicare, such as doctor visits, surgeries, lab work, and so on.
You might pay $5 to see a primary care doctor. Specialists will often be more – a $50 specialist copay is quite common. Some of the higher copays may come in for diagnostic imaging, hospital stay, and surgeries.
You can usually expect to spend several hundred on copays for these items. However, this varies greatly between states, so review plans in your county to get the details.
Medicare Advantage plans do offer extra benefits like routine dental, vision, or hearing. Some plans include gym memberships. When searching for Medicare Advantage plans with dental and vision, our experts here at May River Medicare can help you compare those ancillary benefits between carriers and text you a link to check out the carriers dental network.
Medicare Advantage Plans Networks
In exchange for lower premiums that Advantage plans offer, you agree to play by certain rules. Most Medicare Advantage plans have HMO or PPO networks.
Medicare HMO networks are generally required to treat only with network providers, except in emergencies. You will usually need to select a primary care physician. That physician can coordinate a referral if you need to see a specialist. There are some HMO plans that offer a point-of-service feature where you can see out-of-network providers in certain circumstances.
Medicare HMO plans are the most prevalent type of network. They represent 70% of all Medicare Advantage plans on the market.
Medicare PPO networks allow you to see doctors outside the network, but you’ll have substantially higher out-of-pocket spending to do so.
In limited counties, there are Medicare Private-Fee-for-Service plans. These plans may or may not include Part D. How you access care is also different. While this plan type was very common in the past, it has been slowly phased out in most areas. Read more about Medicare PFFS plans here.
Basic Medicare Advantage Rules
If you are deciding between Medicare Advantage and Medigap, you’ll want to consider some of the rules before you enroll.
You must be enrolled in both Medicare Part A & B and live in the plan service area. Some people think they can drop Part B if they enroll in Medicare Advantage. That is incorrect If you drop Part B while enrolled, you will immediately be disenrolled from your Medicare Advantage plan.
Use network doctors and hospitals for the lowest out-of-pocket costs. Plans may have HMO or PPO networks. Most Medicare HMO plans do not cover anything out of network except emergencies. In PPO networks, seeing a provider outside the network will result in higher spending for you.
Advantage plans may require prior authorization for certain procedures
You may need to obtain a referral from your primary care physician before seeing a specialist on many HMO plans.
Put your red, white, and blue Medicare card in a safe place. Do not give it to any of your healthcare providers. If they bill Medicare, those bills will be rejected because they should have been sent to your Medicare Advantage insurance company for processing.
You must direct your providers to bill your Medicare Advantage plan. People who enroll in Advantage plans for Medicare are agreeing, for the rest of the calendar year, to be covered by the plan instead of Original Medicare.
Watch Video On the Pros and Cons of Medicare Advantage Plans
Click Image Below to Get Your Free Plan G versus Plan N Comparision edicare Advantage
Medicare Advantage Enrollment Periods
Medicare Advantage plans have lock-in periods. You can enroll in one during the Initial Enrollment Period when you first turn 65. After that, you may enroll or dis-enroll only during certain times of the year. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year. You may only dis-enroll from an Advantage plan during certain times of the year unless you qualify for a special enrollment period due to a specific circumstance.
The Annual Election Period in the fall is the most common time to change your Medicare Advantage plan. This period runs from October 15th – December 7th each fall. Changes made to your enrollment will take effect on January 1st If you decide to leave an MAPD and return back to Original Medicare, you must notify your Medicare Advantage plan carrier. Otherwise, Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare.
Some people join Medicare Advantage plans without doing any research about how these plans work or speaking with an agent who can advise them. Therefore they don’t know about all of these rules. They may find themselves enrolled in a plan that their doctor doesn’t accept or that doesn’t include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan.
For this reason, Congress designed the Medicare Advantage Open Enrollment Period that runs from January 1st – March 31st each year. During this time, you can disenroll from any Medicare Advantage plan and return to Original Medicare. You will be allowed to add a standalone Part D drug plan.
Unfortunately, this does not guarantee that you can return to the Medigap plan you had before. Unless this was your first time ever in a Medicare Advantage plan, then you will usually have to answer health questions and go through medical underwriting to get re-approved for Medigap. Consider this before dropping any Medigap plan to go to Medicare Advantage.
Your other option during the Medicare Advantage Open Enrollment Period is to change from your current Medicare Advantage plan to a different Medicare Advantage plan. Please be aware that you can only use this period once per calendar year.
Medicare Advantage Open Enrollment Period
Some people join Medicare Advantage plans without doing any research about how these plans work or speaking with an agent who can advise them. Therefore they don’t know about all of these rules. They may find themselves enrolled in a plan that their doctor doesn’t accept or that doesn’t include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan.
For this reason, Congress designed the Medicare Advantage Open Enrollment Period that runs from January 1st – March 31st each year. During this time, you can disenroll from any Medicare Advantage plan and return to Original Medicare. You will be allowed to add a standalone Part D drug plan.
Unfortunately, this does not guarantee that you can return to the Medigap plan you had before. Unless this was your first time ever in a Medicare Advantage plan, then you will usually have to answer health questions and go through medical underwriting to get re-approved for Medigap. Consider this before dropping any Medigap plan to go to Medicare Advantage.
Your other option during the Medicare Advantage Open Enrollment Period is to change from your current Medicare Advantage plan to a different Medicare Advantage plan. Please be aware that you can only use this period once per calendar year.
Watch video below to learn all about your Medicare Advantage Open Enrollment Period (One last Chance to Change Plans one time)
Many folks use this Open Enrollment Period to Go Back to Original Medicare by enrolling in a Part D drug plan.
Be sure to pass medigap underwriting BEFORE enrolling in a stand alone Part D drug plan first!
Medicare vs Medicare Advantage
The intent of Congress in creating these plans was to give you options for accessing your Medicare benefits. Some reasons why people might choose an Advantage plan are:
Many plans have low monthly premiums (although you must continue to pay your Medicare Part B premium )
You pay for medical services as you use them in the form of copays and coinsurance.
Unlike Original Medicare, Medicare Advantage plans have an out-of-pocket maximum cap to protect you against catastrophic spending.
The convenience of having your medical and Part D drug benefits rolled into one plan. Advantage plans with drug coverage are known as
MAPDs.
Some plans may include benefits for things like limited vision coverage. Limitations, copayments, and restrictions may apply.
