How to Pick the Best Medicare Advantage Plan for You

Tamera Jackson by Tamera Jackson | Licensed since 2007
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This article was updated on: 09/15/2018

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If you’ve decided that a Medicare Advantage plan is best for you, you’re one of more than 20 million who have made a similar decision, according to the Centers for Medicare and Medicaid services in 2017. 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 the best 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 the best Medicare Advantage plan is 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 best Medicare Advantage plan for you may depend on how you want to access primary care doctors, specialists, and hospitals, and whether or not you have a special circumstance.

  • HMO: 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: 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.
  • PFF: like a PPO, you will not need to choose a primary care physician nor do you need a referral to see a specialist. Just be aware that not all Medicare providers accept this plan.
  • 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.

Read more about different types of Medicare Advantage plans.

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:

Prescription drugs

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:

  • Routine hearing services and hearing aids
  • Routine eye exams and eyewear
  • Fitness programs

Medicare Advantage plan cost

Different Medicare Advantage plans may have different out-of-pocket costs.

Premium

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.

Copay

A copay is usually a set dollar amount, for example, $45, you must pay when you receive a specific medical service. Some Medicare Advantage plans may charge a $0 copay for an office visit with a primary care doctor and some plans may charge a copay for visit with a primary care doctor.  Many plans charge a copay for a visit with a specialist. If you have a PPO plan, the plan may charge you a higher copay for a visit to a doctor out-of-network. Preventative services may come with a $0 copay with some Medicare Advantage plans.

Some services you may have to pay a copay for are (this list is not exhaustive):

  • Emergency room visits
  • Ambulance services
  • Outpatient surgery
  • Hospitalization
  • Outpatient rehabilitation services
  • Skilled nursing facility

Deductible

Some Medicare Advantage have a deductible 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.

Out-of-pocket maximum

One benefit of Medicare Advantage over Medicare Part A and Part B is that Medicare Advantage plans may have out-of-pocket maximums. This is usually an amount that you pay in a set time period, usually 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. If you like, use the other links to request a phone appointment or an email from me. I’ll send you Medicare information tailored to your needs. To browse plans now, try the Compare Plans buttons on this page.

*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.

*A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency.

 

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