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Medicare Advantage Plans Explained

Victoria Burke by Victoria Burke | Licensed since 2011

This article was updated on: 07/28/2015

There are different ways to get your Medicare coverage. Many people are automatically enrolled in Original Medicare, Part A and Part B, when they turn 65. Original Medicare doesn’t include prescription drug coverage or routine dental care, but some Medicare Advantage plans may include these benefits, and more.

Unlike Medigap insurance, Medicare Advantage (Medicare Part C) plans don’t offer coverage to supplement Original Medicare. Instead, Medicare Part C plans are a private insurance alternative to the government program. With this option, you get all your Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage through the insurance company instead of directly through the government. Medicare Advantage plans that include drug coverage can give you all your Medicare benefits in one policy; these are known as Medicare Advantage Prescription plans.

When you join a Medicare Advantage plan, you’re still in the Medicare program, and you’re still required to pay your monthly Medicare Part B premium; however, your Medicare services are covered and administered through a single policy.

There are four main types of Medicare Advantage plans: Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO) plans, Private Fee-For-Service (PFFS) plans, and Special Needs Plans (SNPs). Less common Medicare Part Advantage plan options include HMO Point-Of-Service (HMO POS) plans and Medical Savings Account (MSA) plans.

What does a Medicare Advantage plan cover?

  • Medicare Advantage plans must cover all of the medical and hospital services that Original Medicare covers, except hospice care (Original Medicare covers hospice care even if you’re enrolled in a Medicare Advantage plan).
  • All types of Medicare Advantage plan options cover emergency and urgent care.
  • Medicare Advantage plans may offer extra coverage, such as routine vision and dental, hearing benefits, or memberships to health and wellness programs.
  • Many plans include Medicare prescription drug coverage, as mentioned above.

How do I qualify for a Medicare Advantage plan?

You can generally qualify for a Medicare Advantage plan if you meet these conditions:

  • You have Medicare Part A and Part B coverage.
  • You live in an area serviced by the plan you want to enroll in.
  • You don’t have end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant), in most cases. There are exceptions, so if you have ESRD and want to get a Medicare Advantage plan, contact the plan you’re considering and ask.

What will a Medicare Advantage plan cost?

The costs of a Medicare Advantage plan can vary from one plan to another and one location to another. Here are some questions to consider when purchasing a Medicare Advantage plan:

  • Does the plan charge a monthly premium in addition to your Medicare Part B premium?
  • Does the plan have an annual deductible?
  • Is there a maximum out-of-pocket limit?
  • What type of health services do you need? How often?
  • Does this plan have network restrictions? Will you be using network providers or out-of-network providers?
  • If the plan covers prescription drugs, are all your medications covered?
  • How much will you pay for each service or visit (copayments or coinsurance), both in-network and out-of-network?
  • Are there any additional benefits in the plan, such as routine vision or dental coverage? Do you need them? What do these benefits cost?

Since private insurance companies offer Medicare Advantage plans, costs and benefits will vary. It’s important to do your homework and compare plans before enrolling to make sure that the benefits and rules of the plan you select meet your needs and budget.

When can I sign up for a Medicare Advantage plan?

There are a few time periods when you can enroll in a Medicare Part C plan.

  • The Initial Coverage Election Period (ICEP) is an eligibility period for enrolling in a Medicare Advantage plan that begins three months immediately before you are entitled to both Medicare Part A and Part B. The ICEP ends either the last day of the month before you have both Part A and Part B or the last day of the Part B Initial Enrollment Period. If you’re enrolled in Original Medicare during your Medicare Initial Enrollment Period (IEP), automatically or otherwise, your Initial Coverage Election Period and your Initial Enrollment Period happen at the same time. The Initial Enrollment Period runs from three months before the month you turn 65, includes your birth month, and ends three months after that (seven months total). If you didn’t sign up for Original Medicare during the Initial Enrollment Period (if you still have health insurance through an employer or union, for example), your Initial Coverage Election Period is the 3-month period before your Medicare Part B start date. For example, if you enrolled in Medicare Part B during the General Enrollment Period (January 1–March 31), your Medicare Part B start date would be July 1, so your Initial Coverage Election Period would be April 1 to June 30.
  • The Annual Election Period (AEP) runs from October 15 to December 7 each year. You can switch from Original Medicare to a Medicare Advantage plan at this time. If you’re already enrolled in a Medicare Advantage plan and want to switch plans, the best time to do so is during the Annual Election Period.  When you change Medicare plans during the Annual Election Period, your new coverage generally begins on January 1 of the following year.
  • In some cases, you may be able to change Medicare Advantage plans during Special Election Periods (SEPs). Situations that qualify you for a Special Election Period include (but are not limited to) moving to a new address, losing your current coverage, qualifying for other coverage, or changes in your current plan that affect your health benefits. The dates and types of changes you can make vary according to each health plan.
  • If you’re enrolled in a Medicare Advantage plan and want to switch back to Original Medicare, Part A and Part B, you can do so during the Medicare Advantage Disenrollment Period, which runs from January 1 to February 14 each year.

Medicare Advantage plans, and the insurance companies that offer them, do vary depending on your location. Ask me about anything else you’d like to know. You can learn more about who I am with my photo and profile below. Or, use one of the links below to set aside some time to talk with me by phone, or ask me to email you with more information. If you want to start comparing the plans available in your area, click the Compare Plans buttons on this page. If you’re ready to discuss your Medicare needs now, we’d welcome a call from you.

Call Medicare.com’s licensed insurance agents at 1-844-847-2659, TTY users 711; Monday through Friday, 8AM to 8PM ET.

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