Medicare Advantage Programs

Medicare Advantage Plan Part C

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are a type of health plan offered by a private company contracted by Medicare (and meets federal standards).

In short, the federal government pays these MA Plan insurers a set amount for each person who enrolls. However, you (the enrollee) will pay:

Part A premiums (if any)
Part B premiums
The MA plan’s premium (if any)
Any deductibles, copayments, or coinsurance

What do Medicare Advantage Plans cover

Enrollees receive Part A and Part B coverage through MA Plans rather than through Original Medicare.
Some MA Plans may include drug coverage (Part D) and other additional benefits:

Vision and hearing exams
Medicare advantage plan dental coverage (may charge an additional premium)
Foot care
Yearly routine exams
Gym memberships

Medicare Advantage Plans compared

Medicare Advantage Plans include;

Other less common types of MA Plans available include

HMO Point Of Service (POS) Plans and
Medicare Medical Savings Account (MSA) Plan.

Advantages of Medicare Advantage Plans

Low monthly premiums. Some plans do not charge any monthly premium.
Some plans have superior benefits compared to Original Medicare.

Disadvantages of Medicare Advantage Plans

Yearly contracts. Plans have the option to not renew or negotiate their contracts.
Subject to annual reviews. Plans can change benefits, and review upwards the premiums and copayments on an annual basis.
Usually associated with higher annual out-of-pocket expenses as compared to Original Medicare (with a Medigap plan).
May prove tricky if your preferred doctors or hospitals are not under the network providers list or are not willing to accept the plan’s payment terms.

How do Medicare Advantage Plans Work

Individuals can buy MA Plans in several ways:

Contact the MA Plan
Call SHIBA at 1-800-562-6900 to assist in enrollment.
Enroll online via www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
Contact a local agent or broker (by law, agents and brokers are not allowed to conduct door-to-door unsolicited sales).

The beneficiary will pay the Medicare monthly premium to the federal government, but coverage (inpatient hospital (“Part A”) and outpatient (“Part B”) services) will be provided by a contracted private insurance company. Most plans include prescription drug (“Part D”) coverage.
In most cases, beneficiaries are limited to the plan’s health care in-network providers (non-emergency out-of-network coverage may be allowed but at a higher cost.).

MA plans are allowed to set limits on what needs to be paid out-of-pocket annually for covered services.

How to choose Medicare Advantage Plan

The first step is to determine;

If the medical providers take the MA plan.
Do they require a referral when consulting a specialist
Their coverage areas. Will it provide coverage if you live in another state for part of the year? Many plans provide coverage within certain service areas for at least 6 months of the year(except for emergency care).

The second step is to ensure the plan includes:

Is the plan charging Monthly premiums
If any what are the copayments for various services
What are the out-of-pocket limits
Actual Costs of using non-network providers

Lastly, determine the availability of Special Needs Plans within the service area.

This is most important if you are receiving long-term care, or on Medicaid, or live in a nursing home. When choosing other types of MA plans, ensure:

The plan’s in-network providers are certified to accept Medicaid.
In-network providers are billing correctly/or refer to Medicaid providers as needed.
Providers are well aware of what’s covered by Medicaid and what’s covered by the plan.
You pay the monthly premiums as Medicaid does not cover MA plan premiums.

Enrollment Period for Medicare Advantage

Common enrollment periods are:

Initial Coverage Enrollment Period: when you first become eligible (at age 65 or have a disability) to join Medicare (Parts A and B).
Annual Enrollment Period: This is the period between Oct. 15 – Dec. 7 of each year when an individual can join, switch, or drop a plan. Coverage for plans usually begins on January 1 (as long as the request was made by December 7).
Medicare Advantage Open Enrollment Period: Jan. 1 – March 21 of each year, or within the first three months after you get Medicare and you’re in a Medicare Advantage Plan. This is applicable if you have other Medicare coverage, you can change to Medicare Advantage and vice versa during annual open enrollment.

Other enrollment periods may apply to an enrollee’s situation.

Medicare Advantage Plan costs

The standard Part B premium amount is $170.10 in 2022 ($164.90 in 2023) (may be higher depending on your income).

Medicare Advantage maximum out of pocket

The average out-of-pocket limit for MA Plans is $4,972 for in-network services and $9,245 for both in-network and out-of-network services (PPOs)

Since 2011, out-of-pocket limits for services covered under Parts A and B by MA Plans are regulated by federal laws.

For the year 2022, the out-of-pocket limit cannot exceed $7,550($8,300 in 2023) for in-network services and $11,300($12,450 in 2023) for in-network and out-of-network services combined (Part D has an out-of-pocket threshold of $7,050(2022), above which enrollees pay 5% of costs).

Different plans may have different in-network caps or a cap for in- and out-of-network services.

Medicare Advantage vs Medicare

This is mostly visible from a beneficiary’s point of view, key differences include.

Cost of Plan

Original Medicare will charge for standardized Part A and Part B costs, including monthly Part B premium (80%). Enrollees pay 20% coinsurance for Medicare-covered services when seeing an in-provider and after meeting their deductible.

As for Medicare Advantage, some plans may charge a monthly premium (in addition to Part B premium) and cost-sharing varies from plan to plan. Copayment is paid for in-network care.

Medigap

Enrollees in Original Medicare are eligible for enrollment into a Medigap policy to cover Medicare cost-sharing.

Individuals with a Medicare Advantage Plan Cannot purchase a Medigap policy.

Provider Access

With Original Medicare, coverage is available from any facility that accepts Medicare (participating and non-participating).

Medicare Advantage typically provides coverage through in-network providers.

Referrals

Original Medicare enrollees need to get referrals when visiting specialists.

Medicare Advantage enrollees typically do not need referrals when seeing a specialists

Drug coverage

With Original Medicare, you are expected to sign up for a stand-alone prescription drug plan as a standalone.

In most cases, the Medicare advantage plan provides prescription drug coverage (although you may be charged a higher premium).

Out-of-pocket limit

Original Medicare has No annual out-of-pocket limit.

On the other hand, Medicare Advantage Plan has an Annual out-of-pocket limit. The plan provides full coverage only after you reach the limit.

Other benefits

Original Medicare doesn’t cover vision, hearing, or dental services

Medicare Advantage Plan May cover additional services, including vision, hearing, and/or dental (additional benefits usually increase the premium and/or other out-of-pocket costs).

Bottom Line

Please Note:

You need to have Original Medicare (Parts A and B) to be eligible to enroll in an MA plan. Also, in most cases, you cannot have a stand-alone Medicare Part D plan and the Medicare Advantage plan.
Medicare Advantage plans are NOT the same as Medicare supplement plans. If you were enrolled in a Medicare supplement policy and later enroll in a Medicare Advantage plan, you won’t be able to get coverage from the Medicare supplement policy.
If you cancel your supplement policy after enrolling in an advantage plan, you are no longer guaranteed coverage and choose to switch back (however, a few exceptions apply to this rule).
Medicare Advantage plans by law must provide the same benefits (if not more) as the Original Medicare, albeit with different rules, costs, and restrictions. They can also cover certain benefits that are not in the Original Medicare.

Finances and Taxes

For all your Financial and tax information