Medicare Advantage Plans

Leverage the expertise at PTI Consulting Services to weigh your Medicare coverage options.

What are Medicare Advantage Plans?

Medicare Advantage plans, also known as Medicare Part C, are another way Medicare beneficiaries can receive benefits through private insurance companies.

A Medicare Advantage plan combines the benefits of Original Medicare, Part A (hospital) and Part B (medical), into a single plan. Medicare Advantage plans often include additional benefits not covered by Original Medicare, such as prescription drug coverage (Part D), dental and vision, hearing, and wellness programs. A Medicare Advantage plan can provide lower out-of-pocket costs and flexibility in choosing healthcare providers and services.

When you enroll in a Medicare Advantage plan, you still have Medicare coverage. However, with a Medicare Advantage plan, your healthcare services are managed through a private insurance plan, which usually includes a broker or agent (like us!)

Types of Medicare Advantage Plans

These are the main types of Medicare Advantage plans:

• Health Maintenance Organization (HMO): An HMO plan requires you to partner with and use doctors and hospitals within the plan's network, except in emergencies.

• Medicare Medical Savings Account (MSA): An MSA plan is similar to a Health Savings Account (HSA). Unlike other Medicare Advantage plans, an MSA doesn’t usually have a network of doctors, providers, hospitals, etc.

• Preferred Provider Organization (PPO): A PPO plan allows you to partner with and use doctors and hospitals outside the network, but often this flexibility comes at a higher cost.

• Private Fee-for-Service (PFFS): A PFFS plan breaks down coverage and cost by determining how much the plan will pay doctors, other healthcare providers, and hospitals and how much you must pay for care.

• Special Needs Plan (SNP): An SNP plan is available to people who have specific diseases or conditions, are eligible for Medicare and Medicaid, or live in certain facilities (like a nursing home).

Benefits of Medicare Advantage Plans

When looking at Medicare Advantage plans, these are the main benefits you could experience: 

• Comprehensive Coverage: Medicare Advantage plans allow you to consolidate coverage into a single plan. These plans typically include Medicare Part A (hospital) and Part B (medical) coverage, and many also offer Part D prescription drug coverage. Additionally, a Medicare Advantage plan could cover other health-related needs like dental, vision, hearing, senior wellness, fitness memberships, and medical appointment transportation.

• Cost-Effective Options: Medicare Advantage plans often have lower out-of-pocket costs than Original Medicare. This can include lower deductibles, copayments, and coinsurance for covered services. Some plans also have annual out-of-pocket maximums, providing financial protection against high healthcare expenses.

• Managed Care Coordination: Many Medicare Advantage plans, such as HMOs or PPOs, operate under managed care models and can provide coordinated care options for beneficiaries. These plans may require you to choose a primary care physician and obtain referrals to see specialists.

• Flexibility in Provider Choice: While some Medicare Advantage plans require you to use network providers, others offer flexibility to see out-of-network providers for a higher cost. This flexibility can benefit those who prefer continuity of care with their current healthcare providers.

• Medicare Star Ratings: Medicare uses a five-star rating system to evaluate the quality of Medicare Advantage plans. Plans are rated on customer service, member satisfaction, and healthcare outcomes. 

What to Consider When Choosing a Medicare Advantage Plan

When selecting a Medicare Advantage plan, it's essential to consider your individual healthcare needs, including additional benefits/coverage, prescription drug coverage, provider networks, and out-of-pocket expenses. Here are some factors to evaluate:

• Costs: Compare the monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket-maximums for each Medicare Advantage plan against your current coverage.

• Coverage Needs: Review the plan's benefits to ensure they align with your healthcare needs, including coverage for prescription drugs, dental, vision, and other services.

• Plan Ratings: Use plan ratings to gauge the quality and performance of the plan. 

• Prescription Drug Coverage: Ensure your prescription drugs are included in the plan’s formulary (list of covered medications) and accessible at your preferred pharmacies.

• Provider Network: Determine if the plan’s network includes or is accepted by your preferred healthcare providers (primary doctor, specialists, etc.).

When to Enroll in Medicare Advantage Plans

You can enroll in, switch, or drop a Medicare Advantage plan during one of the two main enrollment seasons:

• Annual Enrollment Period (AEP): Every year from October 15th to December 7th, you can add or make changes to your Medicare Advantage plan.

• Initial Enrollment Period (IEP): This is the seven-month window around your 65th birthday when you first become eligible for Medicare. It starts three months before your 65th birthday, includes your birthday month, and extends three months after.

• Open Enrollment Period for Medicare Advantage Plans (OEP): If you're enrolled in a Medicare Advantage plan, you can switch to a different plan or return to Original Medicare from January 1st to March 31st each year.

• Special Enrollment Periods (SEPs): Certain life events may qualify you for a Special Enrollment Period.

Understanding the Difference Between Medicare Supplement & Medicare Advantage Plans

It’s important to know the differences between Medicare Advantage plans (Part C) and Medicare Supplement/Medigap plans:

• Medicare Supplement plans work with Original Medicare, while Medicare Advantage plans are an alternative to it. 
• Medigap plans work alongside Original Medicare, allowing you to see any Medicare-approved provider and offering more predictable costs. 
• Medicare Advantage plans often include additional benefits such as vision, dental, and wellness programs, but they usually require using in-network providers.