What You Should Know
- Nearly 25,000,000 seniors are enrolled in Medicare Advantage plans, as of June 2020.
- To choose a plan, determine personal needs and look at how plans can effectively meet them.
- Every region of the country has access to a different array of Medicare Advantage plans.
- Anyone who is eligible for or already enrolled in Medicare Parts A and B is eligible for Medicare Adv
For seniors seeking options outside of Original Medicare, a Medicare Advantage plan can be an excellent alternative. Also known as Medicare Part C, a Medicare Advantage plan is purchased through a private insurer, not the government. It’s a popular choice, too; nearly 25,000,000 seniors are enrolled in Medicare Advantage plans, as of June 2020. With enhanced flexibility, a wide range of cost options, and numerous plan models, there’s a lot to be gained by choosing Medicare Advantage over Original Medicare.
Medicare Advantage plans are required to provide, at minimum, the benefits included in Original Medicare Parts A and B, but are permitted to offer additional coverage options, as well. As such, no two Medicare Part C plans will be exactly alike. Coverage can vary significantly from one insurance provider and plan type to another, so it’s very important for seniors to do their homework to find the best possible plan to meet their needs.
What Are the Different Types of Medicare Advantage Plans?
Unlike Original Medicare, which is effectively one-size-fits-all, Medicare Advantage plans come with a variety of different options. As Medicare Advantage is sold through private insurance providers, plans are similar in scope to traditional private insurance plans available through standard employment or the Marketplace. There are five different kinds of Medicare Part C plans: HMOs, PPOs, PFFSs, HMO-POSs, and SNPs.
Medicare Advantage Health Maintenance Organization (HMO) Plans
Health Maintenance Organization, or HMO, plans rely on the use of a provider network. Care within the network is often covered to a larger degree under an HMO plan than some other plan types, such as PPOs. HMO plans rarely pay for out-of-network coverage, lowering plan principle costs but potentially creating usage restraints for seniors who travel or may need to seek care outside of a network. With an HMO plan, seniors must designate a primary care provider, and any specialist visits require a referral. HMO plans can include prescription drug coverage but aren’t required to do so.
Medicare Advantage Preferred Provider Organization (PPO) Plans
Preferred Provider Organization, or PPO, plans utilize a network model similar to HMOs but with increased flexibility. Some portions of out-of-network care is usually covered, providing seniors with the option to seek care from a greater range of providers. Consequently, premium costs are generally higher for PPOs than all other plan types. PPOs don’t require a designated PCP and specialist visits don’t need a referral to qualify for coverage. Some PPO plans include prescription drug coverage, but this isn’t universal.
Medicare Advantage Private Fee-for-Service (PFFS) Plans
Private Fee-for-Service, or PFFS, plans don’t use a network model but rather reimburse for medical treatment based on a set fee schedule. This model yields maximum flexibility, as most providers who accept Medicare will accept PFFS plans. However, as the cost of care can vary from one facility and provider to another, seniors may need to price shop doctors and hospitals to make the most of coverage limits. PFFS plans can sometimes include Part D prescription drug coverage, but this isn’t a requirement.
Medicare Advantage Health Maintenance Organization-Point of Service (HMO-POS) Plans
A Health Maintenance Point of Service plan is a hybrid between an HMO and a PPO. This kind of plan combines the higher coverage levels for in-network care typical for a standard HMO with the increased flexibility of a PPO. For those with extensive needs who can afford higher premiums and want a combination of coverage and convenience, an HMO-POS plan can be a great compromise. These plans don’t have to include prescription coverage, but some do.
Medicare Advantage Special Needs Plans (SNPs)
Special Needs Plans, as the name implies, are plans designated for those with unique medical needs that may not be well-served by other forms of Medicare Advantage plans. SNPs aren’t open to everyone; they are only a choice for seniors with a qualifying medical condition, such as end-stage renal disease. These plans are designed to best support the specific qualifying medical conditions with specially tailored coverage options. Generally, seniors who qualify for SNPs aren’t permitted to enroll in other forms of Medicare Part C plans. Unlike all other forms of Medicare Advantage plans, SNPs must include prescription drug coverage.
How to Choose a Medicare Advantage Plan
Choosing a Medicare Advantage plan is a personal experience that requires due diligence and an understanding of coverage needs.
Seniors in most areas of the country have access to many different plan types, which can be overwhelming. To choose a plan, they should determine personal needs and look at how plans can effectively meet them. When evaluating plans, ask the following kinds of questions to ensure all requirements can be met:
- What are my medication needs? Do I need a plan with comprehensive medication coverage, or is purchasing a separate prescription drug plan more beneficial?
- Will my current preferred doctors or specialists be covered?
- How much money can I afford to spend on premiums each month? Is a more expensive plan with minimal deductibles, coinsurance, or co-pays a better value?
- Will my travel plans affect my coverage needs?
- Do I need any plan extras, such as vision, dental, or hearing coverage?
- Am I eligible for a Special Needs Plan?
There is no one correct answer when choosing a Medicare Advantage plan. What is best for one senior isn’t necessarily the right choice for another. Enrolling in a Medicare Advantage plan needs to be a personal decision based on individual health and budget requirements.
How Do I Find Medicare Advantage Plans Near Me?
Every region of the country has access to a different array of Medicare Advantage plans. To find locally available plans, start by going to Medicare’s website, Medicare.gov. Click on the “Find Plans” button in the middle of the screen to search for Medicare Part D and Medicare Advantage plans. Users can create an account before evaluating plan options or browse as a guest. Each plan lists out details, including covered services, the in-network hospitals and doctors, and costs. A star rating assigned by Medicare is also included to help users make educated and informed decisions. Seniors who are prepared to make a plan choice can begin the enrollment process online.
Anyone who is eligible for or already enrolled in Medicare Parts A and B is eligible for Medicare Advantage. While enrollment must take place in one of the designated windows, either when first eligible or during open enrollment or a special enrollment period, Medicare Advantage is available to all qualified seniors. Note that some seniors, depending on medical conditions, may only be eligible for SNPs.
Choosing the right Medicare Advantage is an important decision that affects finances and health care. By understanding the available plan types and coverage options, seniors can move forward with Medicare Part C with confidence.
- Sources [-]https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Medicare-Enrollment/Enrollment%20Dashboard.html, last accessed September 2020.
https://www.medicare.gov/, last accessed September 2020.
https://www.medicare.gov/supplements-other-insurance/whats-medicare-supplement-insurance-medigapxTrusted SourceThe Official U.S. Government Website for Medicare ()Official U.S. Government Website for Medicare managed and paid for by the U.S. Centers for Medicare & Medicaid Services.Government AuthorityGo to Source, last accessed September 2020.
https://www.medicare.gov/plan-compare/#/?lang=en, last accessed September 2020.
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.