What is Medicare Advantage?

Medicare Advantage is related to Medicare, which is the federal healthcare plan for the following groups:

• Individuals age 65 and older
• Certain individuals younger than 65 with disabilities
• Individuals with End-Stage Renal Disease (permanent kidney failure requiring dialysis or kidney transplant)

Medicare, also sometimes called Original Medicare, consists of three parts:

We’re glad you asked! Medicare Part C is Medicare Advantage, which is an alternative to Original Medicare. Private insurance companies that contract with Medicare administer Medicare Advantage plans that bundle Parts A, B, and D. When you have a Medicare Advantage plan, the insurance company, not Medicare, pays for your services.

Medicare Advantage provides the same Part A and Part B coverage as Original Medicare. Most Medicare Advantage plans also provide Part D coverage. Additionally, some Medicare Advantage plans offer coverage for services like vision, dental, hearing, and health and wellness programs, which are not covered by Original Medicare. When selecting a Medicare Advantage plan, you will be able to see exactly what plans cover and what they do not.

Like regular insurance plans that are available through employers or the health insurance marketplace, there are a variety of different types of plans available through Medicare Advantage. These include:

• Health Maintenance Organization (HMO) Plans
• Preferred Provider Organization (PPO) Plans
• Private Fee-For-Service (PFFS) Plans
• Special Needs Plans (SNPs)

Each type of plan has its own rules regarding networks, referrals, primary care doctors, and more. It’s important to review plans carefully, so you choose the one that best suits your healthcare needs.

Because Medicare Advantage plans are administered by private insurance companies, plan availability varies based on your location, and which healthcare providers operate in your area. When you begin your research or enrollment process, you will enter your zip code so Medicare can provide you with accurate information about plans that are available to you.

Premium prices for Medicare Advantage plans vary based on provider, location, coverage, and other factors. Medicare Advantage plans generally use co-payments for out-of-pocket costs, so you will know upfront how much you will owe for services not covered by your plan. Additionally, most Medicare Advantage plans have out-of-pocket spending caps, so once you hit your limit for the year, your plan will cover 100 percent of most services.

The doctors, hospitals, and other healthcare providers who accept your Medicare Advantage plan will depend on your plan provider, plan type, and geographic location. If you already have particular doctors or providers you want to keep using, it’s a good idea to check if they are in a plan’s network before enrolling.

Anyone who is eligible for Original Medicare is eligible for Medicare Advantage, except those with End -Stage Renal Disease (ESRD). Individuals with this condition may need to enroll in a Medicare Special Needs Plan (SPN).

Also, individuals who are enrolled in Medicare Supplement Insurance, also known as Medigap, cannot enroll in a Medicare Advantage plan, unless they drop their supplemental insurance.

Yes. You can switch your coverage, either from Original Medicare to Medicare Advantage, or vice versa, once a year during specific open enrollment periods.

Choosing between Original Medicare and Medicare Advantage is a personal decision based on a number of factors. There is no one-size-fits-all choice. It depends on what works best for you and your healthcare needs.

When choosing between Medicare Advantage and Original Medicare, here are some things to consider:

• Coverage: Medicare Advantage covers medical and hospital costs, as well as prescription drugs, dental, vision, and hearing. Original Medicare only covers medical and hospital costs, and prescription drugs through Part D.
• Out-of-Pocket Costs: Medicare Advantage plans have out-of-pocket spending caps, meaning that once you hit your out-of-pocket limit for the year, your plan will cover 100% of the cost for most services. There is no cap on out-of-pocket costs in Original Medicare plans. Additionally, Original Medicare will only pay for a certain number of days in hospitals and skilled nursing facilities.
• Coinsurance vs. Copayments: Medicare Advantage uses copayments, so you will know your out-of-pocket costs upfront for each service. Original Medicare uses coinsurance, meaning that customers pay a percentage of the total cost of the care, so out-of-pocket costs will fluctuate based on the overall cost of the care or service provided.
• Network: Medicare Advantage customers can only go to doctors, hospitals, and other providers in their network. Visiting out-of-network doctors or facilities will result in a higher out-of-pocket cost. In Original Medicare, patients can go to any doctor or facility that accepts Medicare.
• Travel: Depending on the Medicare Advantage plan, emergency care may be covered when you’re out of the U.S. Original Medicare does not cover any services, even emergency care, that are received outside the U.S.

If you think a Medicare Advantage plan is right for you, go here to learn more about comparing Medicare Advantage plans.