Medicare Advantage plans. You’ve seen them on TV and probably gotten flyers in your mailbox. They promise a long list of benefits, $0 premiums, and even say they’ll give you money back on your Social Security benefits.

But is all that hype really true? Actually, it can be! First, however, you’ll need to know how these plans work, what kinds are available, and when you have opportunities to enroll. We’ll answer all those questions today.

What Is Medicare Advantage?

Medicare Advantage is also called Medicare Part C. They are optional plans beneficiaries can choose to increase their benefits under Original Medicare (Parts A and B). However, instead of acting as a secondary form of insurance (like Medicare Supplements do), a Medicare Advantage plan will take your benefits from Parts A and B, add some extras, and bundle them all into one convenient plan.

This bundling action is why some people refer to them as Medicare “replacement” plans. While that’s a good way to think about how you’ll be getting your coverage, technically, your Part A and B are still in place. And, of course, you still have to pay your Part B premium.

Private insurance companies sell Medicare Advantage plans, so their benefits vary significantly. Plans that include prescription drug coverage are referred to as MAPD plans, while those without them are MA-only plans. The majority also include:

● Routine and restorative dental benefits

● Vision and hearing services (eyeglasses, hearing aids)

● Meal delivery after hospitalizations

● Transportation to and from appointments

● Gym memberships

Yes, Medicare Advantage plans are often more affordable than other Medicare options. And yes, some do have $0 monthly premiums. But, be sure to understand the copayments or coinsurance costs associated with the plan. For example, you may have an annual deductible or a copayment at every doctor’s visit. In addition, most plans have high copayments for inpatient hospital visits - typically around $300 per day for the first five or six days.

The Four MOST COMMON Kinds of Medicare Advantage Plans

The next thing to know about Part C plans is that there are four different kinds of plans. The kind you enroll in will greatly impact which providers and facilities you can go to for your healthcare needs. Let’s take a brief look at each kind.

Health Maintenance Organizations (HMO)

HMO plans require their members to receive care from a contracted provider. If the provider is not in-network with the plan, there will be no benefits, and the member must pay the entire cost. Members must choose a primary care physician (PCP) and get a referral to a specialist if needed. HMO plans do offer out-of-network benefits in emergency cases.

Preferred Provider Organizations (PPO)

PPO plans also work best if enrollees use in-network providers, but they allow for out-of-network benefits. In those cases, the beneficiary will have to pay more for services. For example, maybe a plan has a $10 copay for in-network providers but a $30 copay for out-of-network providers. Enrollees do not need to designate a PCP, nor do they need referrals for specialists.

Private Fee-for-Service (PFFS)

PFFS plans do not always have provider networks. Instead, beneficiaries can see any provider that agrees to accept the plan’s payment terms. The member can use the plan if the provider agrees to bill the insurance company. The downside to PFFS plans is that providers can choose to stop accepting the payment terms at any time.

*Special Needs Plans (SNP)

SNPs are tailored to specific groups of individuals. There are three types of SNPs:

C-SNP - designed for people with chronic conditions
I-SNP - designed for people who reside in institutions
D-SNP - designed for people who are eligible for Medicare and Medicaid

SNPs are designed to provide benefits that will help certain groups. For example, a C-SNP designed for diabetics will include the right prescriptions, specialists, and services that will enable that person to get the care they need. All SNPs include drug coverage. (Inquire about eligibility in SNP’s with a trusted resource)

Medicare Advantage Eligibility and Enrollment

There are two requirements you must meet before enrolling in Part C. First, you must already be enrolled in Original Medicare. Second, you must live within the specific plan’s service area. Not all plans are offered in all counties, and you can only enroll in plans that are offered in your zip code.

In addition, to be eligible to enroll in one of the SNP, you must meet other certain criteria. For example, you must be eligible for Medicaid to enroll in a D-SNP. (These are often the plans referred to in commercials promising your money back on Social Security. This is true, but not everyone will qualify.)

Individuals are first eligible to enroll in a Medicare Advantage plan around their 65th birthday, during their Initial Enrollment Period (IEP). You can also enroll or change plans if you have a life event that qualifies you for a Special Enrollment Period (SEP). These “life events” include moving, leaving an employer’s group plan, or becoming eligible for an SNP.

Annual Enrollment Period for Medicare Advantage

The Annual Enrollment Period (AEP) is a crucial time for every Medicare beneficiary. It occurs each year from October 15 to December 7. Beneficiaries are allowed to change their current Medicare Advantage plan to another plan, which would then begin on January 1 of the upcoming year.

Even if you are satisfied with your current plan, you should still take advantage of AEP for several reasons. First, your current plan might change, and you may not like those changes. Premiums and benefits can change, or your current providers might change their network status.

Second, Medicare Advantage continues to grow in popularity every year. Insurance companies have a lot of competition, so they always try to provide more and better benefits. Even if you love your plan now, a new one may be on the market with even more coverage. It is always worth reviewing your options during AEP.

If you’d like to learn more about Medicare Advantage or want help comparing plans, call Jackson Insurance Brokers. Our licensed agents are experts in the Medicare industry and can ensure you’re on the best plan for you.