Do I Need a Medicare Advantage Plan?

Steven Mott by Steven Mott | Licensed since 2012
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This article was updated on: 09/15/2018

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Do I Need a Medicare Advantage Plan?

By the end of 2016, according to a report from the Centers for Medicare & Medicaid Services (CMS), around 33% (or nearly 19 million) of Medicare beneficiaries were enrolled in Medicare Advantage plans or other Medicare health plans, and their popularity continues to grow.  Read on if you are wondering if a Medicare Advantage plan would be the right choice for you.

What you need to know about Medicare Advantage plans

The Medicare Advantage program (also known as Medicare Part C) is an alternative way to receive your Medicare Part A and Part B benefits. Instead of getting your Medicare benefits directly from the federal government, they’re administered by a private insurance company contracted with Medicare. Except for hospice care, which remains covered under Medicare Part A, a Medicare Advantage plan provides at least the same level of coverage as Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

Many Medicare Advantage plans contract with health-care facilities, doctors, and other medical professionals and suppliers to deliver care and services to members of their Medicare Advantage plans. This arrangement is referred to as a Medicare Advantage plan’s provider network.  Health-care providers who participate in a Medicare Advantage plan’s network agree to help coordinate care and provide services at a cost that may be lower than their normal fees.  This might mean lower out-of-pocket costs to you if you choose to enroll in a Medicare Advantage plan. However, costs (such as deductibles, copayments, coinsurance, and premiums) vary among plans.

To enroll in a Medicare Advantage plan, you must have Medicare Part A and Part B and live in the Medicare Advantage plan’s service area (and in most cases, you must not have end stage renal disease, which is kidney failure requiring regular dialysis or a kidney transplant).

Why might I need a Medicare Advantage plan?

The type of Medicare coverage that works best for you is your decision. Here are some of the ways Medicare Advantage plans might appeal to some beneficiaries:

Medicare Advantage plans: scope of benefits

Medicare Advantage plans often offer more benefits than Medicare Part A and Part B. Many Medicare Advantage plans offer additional benefits which may include one or more of the following (this may not be a complete list):

  • Medicare Part D prescription drug coverage
  • Routine vision care
  • Routine hearing care
  • Routine dental care
  • Gym membership and/or other wellness programs

You might find a Medicare Advantage plan that provides the benefits you want. And you might appreciate the convenience of getting all of your health-care coverage in a single plan rather than dealing with multiple insurance companies.

It’s important to note that if you pay a premium to your Medicare Advantage plan, it’s not the only premium you’ll need to pay. You still need to pay your monthly Medicare Part B premium as well, no matter what Medicare Advantage plan you might sign up for.

Medicare Advantage plans: maximum out-of-pocket costs

You might want to note that Medicare Advantage plans have a maximum out-of-pocket amount. This maximum out-of-pocket amount is the limit (or “cap”) on the amount you might have to pay out-of-pocket for covered services during the year. The out-of-pocket amount can include costs such as copayments, coinsurance, and deductibles. These caps may be different from one Medicare Advantage plan to another. If you spend up to the plan’s maximum out-of-pocket amount, your Medicare Advantage plan may pay 100% for covered hospital and medical services for the rest of the year. (Your premium costs don’t count toward your maximum out-of-pocket costs.)

Medicare Advantage plans: HMO, PPO, HMOPOS plans

If you had group health insurance coverage under an employer or union plan, you might be familiar with health plans such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and HMO point-of-service (POS) plans. Similarly, some common types of Medicare Advantage plans include HMOs, PPOs*, and HMOPOS plans.

Aside from these types of plans that may be familiar to you, there are also Medicare Advantage plans called Medicare Special Needs Plans (SNPs). SNPs are designed to meet the special needs of some Medicare beneficiaries. You might be eligible for a Medicare Special Needs Plan if you have both Medicare and Medicaid coverage; you live in skilled nursing facilities or need skilled nursing care at home; or you have any of certain chronic medical conditions. There are also other types of Medicare Advantage plans – availability and costs may vary.

To get more specific information about Medicare Advantage plans available where you live, you can do any of these:

  • Click on the Compare Plans or Find Plans buttons on this page and enter your zip code.
  • You can also contact me if you would like to discuss your Medicare coverage options or if you want help evaluating Medicare Advantage plans. To schedule a telephone appointment with me or ask me to send you additional information via email, just use the link below.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Benefits, premiums and/or copayments/co-insurance] may change on January 1 of each year.

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