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How to Pick the Best Medicare Advantage Plan for You

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Medicare Advantage is another way to get your Original Medicare (Part A and Part B) benefits through a private insurance company that contracts with Medicare. If you’ve decided that Medicare Advantage is the best way for you to get your Medicare coverage, your next decision will be to decide on the best Medicare Advantage plan. Some states have hundreds of Medicare Advantage plans available, according to the Centers for Medicare and Medicaid Services (CMS) although not all plans may be available in all areas.

Medicare Advantage plans must cover everything that Original Medicare covers (with the exception of hospice care which Medicare Part A still covers) and some of the best Medicare Advantage plans have additional benefits. Some Medicare Advantage plans have premiums as low as $0 but you must continue to pay your Part B premium. According to CMS over 21 million people are enrolled in Medicare Advantage and other health plans in 2018.

What are the different types of Medicare Advantage plans?

You may be familiar with Medicare Advantage plan types through having a similar plan sponsored through an employer. Determining the best Medicare Advantage plan for you depends on how you want access to specialists and whether or not you have a health condition. The four most common types of Medicare Advantage plans are:

  • Health Maintenance Organization (HMO) plans: in most cases you must choose a primary care doctor with an HMO plan and get a referral to see a specialist. You also must get care and services from providers in the plan’s network, with the exception of emergency care and out-of-area urgent care or dialysis. Usually HMOs cover prescription drugs but check with the specific plan.
  • Preferred Provider Organization (PPO) Plans*: Unlike an HMO, you generally don’t need to choose a primary care doctor or get a referral to see a specialist with a PPO. PPO plans have network doctors, health care providers, and hospitals and you generally pay less if you use providers inside the network. Usually PPOs cover prescription drugs but check with the specific plan.
  • Private Fee-for-Service (PFFS) Plans**: PFFS plans are like PPOs in the way that you generally don’t need to choose a primary care doctor and you don’t have to get a referral to see a specialist. You can chose to see a provider who accepts your plan’s terms, but your costs will usually be lower if you stay in network. Not all Medicare providers accept this plan. Usually PFFS cover prescription drugs but check with the specific plan.
  • Special Needs Plans (SNPs): SNPs are limited to people with specific disease or characteristics such as dementia, HIV/AIDS, stroke, cancer, and chronic heart failure, among other conditions. The SNP providers and covered medications are tailored to the groups they serve. For example, a cancer SNP may cover specialists such as oncologists as well as chemotherapy medications. With an SNP you generally must get care from doctors and hospitals in network except emergency care and out-of-area dialysis. All SNPs must provide prescription drug coverage.

What are the added benefits of Medicare Advantage plans?

Medicare Advantage plans are not allowed to exclude any benefits that Original Medicare covers. The best Medicare Advantage plans can offer equal or better coverage as Original Medicare. Medicare Advantage may cover the following:

  • Prescription drugs you take at home
  • Routine dental services such as exams, cleanings, x-rays, fillings and extractions
  • Routine eye exams and glasses
  • Fitness programs and gym memberships

Original Medicare does not generally cover most of the above.

What are the different costs of Medicare Advantage plans?

Cost associated with a Medicare Advantage plan include:

  • Premiums: This is the amount you pay monthly to keep your plan. You must continue to pay your Part B premium even if you have a Medicare Advantage plan. Some Medicare Advantage plans have a monthly premium as low as $0, but these plans may be not necessarily be the best Medicare Advantage plans. Plans with low premiums may have higher copays and deductibles.
  • Copays: A copay is the amount you must pay when you receive a medical service. Usually a copay is a set dollar amount, such as $15 for a doctor visit. Many preventative services such as vaccines and screenings come with a $0 copay.
  • Deductibles: A deductible is the amount you must pay out-of-pocket before your plan begins to pay. So if your deductible is $1,000 annually, you must pay $1,000 for your medical bills before your plan begins to pay. Some Medicare Advantage plans have a $0 annual deductible.

Once you’ve determined your plan type, desired benefits, and cost structure, you are ready to select the best Medicare Advantage plan for you.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover an out-of-network service, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

**A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.

The provider network may change at any time. You will receive notice when necessary.

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