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Songer Benefits, Inc. Blog

All You Ever Wanted to Know About Insurance

What is a Medicare Advantage Plan

When enrolled in Medicare

You are responsible for many out-of-pocket costs related to your health care services. For many years, people on Medicare had only Medigap plans for additional coverage. While these plans have excellent coverage, not everyone can afford them, so Medicare Advantage plans were created to give people another option. In 2021 more than 26 million Medicare beneficiaries were enrolled in a Medicare Advantage plan, so it's fair to say that these plans are gaining in popularity, but 

•          What exactly is a Medicare advantage plan? 

•          How do they work?

•          When can you enroll in a plan?

Medicare Advantage plan

Also known as Medicare Part C, it is a private health insurance plan approved by Medicare. By joining one of these plans, you direct Medicare to pay the advantage plan to provide your medical care and return the advantage plan will deliver all of your part A and Part B health care services they sensually take on your medical risk you must be enrolled in both Medicare parts A&B and live in the planning service area to be eligible. You must also continue to pay your Medicare Part B premium while enrolled in an advantage plan. A popular feature of advantage plans is that they often include a built-in Medicare Part D drug plan which saves you from purchasing that separately. Advantage plans were built with an auto pocket maximum cap as well on your medical spending. You can think of this as a safety net if you have heavy health spending that hits the pocket limit set annually by the plan.

 The plan kicks in and pays the rest for the remainder of the calendar year now; Part D expenses are calculated separately in your copays. 

 •          Drug spending is in addition to whatever you spend on inpatient and outpatient care in any calendar year. 

 •          Medicare advantage policies are not Medigap plans. 

•          They work very differently because they pay instead of Medicare, not after Medicare.

 •          You can enroll in a Medicare Advantage plan during your fall enrollment 

Medicare Advantage plans typically have lower premiums than Medigap plans. 

Still, you may spend more out of pocket throughout the year for your health care services in some cases. This is because you will pay cost-sharing amounts to providers as you seek various health care services. Advantage plans can also offer additional perks and benefits, such as dental vision and hearing. They may even include a free gym membership or an over-the-counter benefit for vitamins and supplements.

Medicare Advantage plans are not required to include these extra benefits. 

Still, of course, they often do so to attract Medicare beneficiaries like you to enroll in their plans so that the insurance company can get paid by Medicare for taking on your medical risk Medicare Advantage plans usually operate an HMO or PPO network of providers HMO plans are popular because of the lower premiums that they often offer in some plans and HMO premium may be as low as zero meaning you pay no premium for the plan other than the Part B premium that you already pay to Medicare when you're enrolled in an HMO plan.

 •          Usually, must receive treatment within network providers 

•          Except in the case of a medical emergency

Your Medicare Advantage provider contracts with certain doctors and hospitals in your local area to form a network, and you will need to select a primary care physician from that network who will coordinate your care if your primary care physician is unable to treat a specific health condition they will issue a referral for you to see a specialist in the network HMO networks are typically more restrictive than PPO networks which will cover next.

PPO Advantage plans have more flexibility than HMO plans 

In a Medicare PPO, you can go outside the plan's network for your services. If the position is willing to bill your plan, you generally pay lower copayments. If you see providers that are in the network, of course, you are 

 •          Not usually required to choose a primary care physician 

•          Referrals to see specialists with the PPO

•          Each plan has its own rules, though, so always check the plan's summary of benefits

•          Evidence of coverage before enrolling

Pros and cons of Medicare Advantage versus traditional Medicare 

With a Medigap plan, and much of this is in the way that you will access your benefits with original Medicare, you have deductibles, and you pay a 20% coinsurance on your Part B healthcare, you can visit any doctor or hospital that participates in Medicare and most do with an advantage plan you will use the plan's network of providers which is usually local you will pay copayments when you receive the various health care services.

 •          For example, you might pay a small copay for a primary care doctor visit

•          Perhaps a higher copay to see a specialist 

•          Some plans will charge you a daily hospital copay 

•          Others might charge a flat amount for the whole stay.

These copayments can sometimes be pricey on some things. You could even pay a coinsurance of up to 20%. We see this commonly with cancer treatment where the plan expects you to pay 20% of chemotherapy or radiation charges up to the plan maximum out of pocket limit, and this is one of the reasons it's so important that people who enroll in a Medicare Advantage plan also enroll in an inexpensive cancer plan to pay them a lump sum benefit in the event of a cancer diagnosis again each plan sets its cost-sharing amounts so you'll want to review those before enrolling to make sure that you can afford them one of the other most significant differences between traditional Medicare.

Medicare Advantage plan is subject to change every year. 

Medicare may have minor changes to the Part A and B deductible. Still, the 20% coinsurance you pay on outpatient services is that Medicare Advantage plans can change your benefits and copays every year. 

For example, you could join a Medicare Advantage plan this year that offers excellent dental and vision benefits. Now it's September, and you get your annual notice of change letter in the mail from your advantage plan, and you read that you are no longer going to have dental and vision benefits next year. Now you might be pretty upset, especially if you haven't upcoming procedure the following year, and then you may want to consider changing plans during the upcoming fall annual election. 

Remember, Medicare has shared this about Medicare Advantage plans limitations. You will need to review the plan materials sent to you in September to see what's changing next year. Copayments and restrictions may apply in each plan benefits formulary pharmacy network provider network premium, and copayments may change on January 1st.

You can change advantage plans during specific election periods.

Unlike traditional Medicare and Medigap plans, advantage plans have lock-in periods. When you enroll in the Medicare Advantage plan, you will have two main enrollment periods where you can change or disenroll from your current plan if you don't qualify for a special election. One is the annual fall election. Also known as the AEP, our busiest time of year, the AEP starts on October 15th and ends on December 7th.

During the AEP, 

 •          You can leave your current plan

•          Enroll in a new advantage plan to begin on January 1st, 

•          Drop your advantage plan entirely and return to traditional Medicare 

•          Pick up a standalone Part D drug plan to go alongside it

The second enrollment period during which advantage plan members can make a one-time change is the Medicare Advantage open enrollment period. This enrollment period runs from January 1st to March 31st every year. You can switch from one Medicare Advantage plan to another advantage plan or disenroll to go to Medicare and a Part D drug plan. This enrollment period is different from the AEP because it's not a time to enroll in a Medicare Advantage plan if you have original Medicare right now. It can only be used by those who already have a Medicare Advantage plan. Medicare Advantage plans have different networks premiums and cost-sharing, and in many urban areas, you may have 20 or 30 plans to choose from. 

Working with an insurance agency specializing in these plans is a great way to consider all the variables before choosing your insurance plan and company. Our team here at Songer Benefits is very familiar with how advantage plans work, so give us a call. Our service is free.