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What is Medicare Advantage?

Medicare Advantage Also Known as Part C

Medicare Advantage plans are an alternative to Original Medicare, Part A and Part B. Instead of having Medicare benefits administered through the government-run program, beneficiaries can choose to get their coverage through a Medicare Advantage plan, available through private insurance companies that contract with Medicare (Government). Medicare Advantage plans are different from Medicare Supplement plans. Some doctors refer to them as Medicare replacement plans or Medicare replacement insurance. These plans often have networks and some plans may require you to get referrals to see a specialist.

Below is the current Medicare Advantage Statistics in our Nation (according to Kaiser Family Foundation):

  1. 59% of Medicare Advantage enrollees are in plans operated by UnitedHealthcare, Humana, or BlueCross/BlueShield affiliates in 2019
  2. 34% of ALL Medicare beneficiaries (22 million) are enrolled in Medicare Advantage plans as of 2019
  3. Out of the 22 million, 62% are in HMO’s with the rest in local or regional PPO’s.
  4. 29% of new Medicare beneficiaries enrolled in an plan during their first year on Medicare.

Medicare Advantage plans has grown in the Medicare program over the past decade and will continue to trend in the Medicare Arena. More than 22 million Medicare beneficiaries are enrolled in Medicare Advantage plans as of 2019. Medicare Advantage plans are private plans alternative to the traditional Medicare (Government) program.

Medicare (Government) pays the Medicare Advantage plan a fee every month to administer your Medicare Part A and B benefits. In order for you to keep your Medicare Advantage plan you must must continue enrolled in both Medicare Part A and B. This means you have to continue paying for your Part B premium each month.

  • Medicare Advantage plans are funded by Medicare (Government). Medicare (Government) pays the Medicare company to facilitate your medical care.
  • With Medicare Advantage plans you will present one ID card for all your services. Your hospitals, doctors and other medical providers will bill the Medicare plan instead of Medicare (Government).
  • Medicare Advantage plans has its own summary of benefits also known as SOB. The SOB will tell you what your co-pays will be for various healthcare services.
  • Medicare Advantage plans offers all the same services as Original Medicare (Government)

In Nevada, some plans have $0 co-pays for Primary Doctors and low co-pays for Specialists. Some co-pays may come in for diagnostic imaging, hospital stay, and surgeries.

Most Medicare Advantage plans have HMO or PPO networks.

  • Medicare HMO networks generally require to treat only with network providers, except in emergencies. You will need to select a primary care physician. That physician will coordinate a referral if you need to see a specialist.
  • Medicare PPO networks allow you to see doctors outside the network but you’ll have substantially higher out-of-pocket spending to do so.
  • Requires that you are enrolled and keep both Medicare Part A & B. Some people have stopped paying their Part B once they enroll in Medicare Advantage. If you drop Part B while enrolled, you will immediately be kicked out of your Medicare Advantage plan.
  • You must live in the plan’s service area.
  • Advantage plans have one health question:  Are you currently receiving routine dialysis for Kidney Failure? (Also known as ESRD – End-Stage Renal Disease)
  • Use network doctors and hospitals for the lowest out of pocket costs. Some companies have plans that HMO or PPO networks. Most Medicare HMO plans do not cover anything out of network except emergencies. In PPO networks, you can see doctors or medical providers outside the network for a higher cost.
  • You need prior authorization for certain procedures, especially in Medicare Advantage HMO plans.
  • You must obtain a referral from your primary care physician before seeing a specialist on many HMO plans

People who enroll in Advantage plans for Medicare are agreeing, for the rest of the calendar year, to be covered by the plan instead of Original Medicare (Government). You will no longer need your Red, White and Blue Medicare card when you receive care. The only card you will need is your Medicare Advantage plan member ID card. This goes the same for your prescription drugs if you have a Medicare Advantage Prescription Drug plan. You get one card that you present for everything.

Some people don’t realize this and join Medicare Advantage plans without the help of an agent. Therefore they don’t know about all of these rules. Sometimes they find themselves enrolled into a plan that their doctor doesn’t accept or that doesn’t include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan.

For this reason, Congress designed the Medicare Advantage Disenrollment Period (MADP). The MADP runs from January 1st – February 14th each year. During this time, you can disenroll from any Medicare Advantage plan and return to Original Medicare.

Unfortunately, this does not guarantee that you can return to the Medicare Supplement plan you had before. Unless this was your first time ever in a Medicare Advantage plan, then you will usually have to answer health questions and go through medical underwriting to get re-approved for Medicare Supplement plan. Consider this before dropping any Medicare Supplement plan to go to Medicare Advantage.

Some reasons why people might choose an Advantage plan are:

  • Most plans have low monthly premiums (although you must continue to pay your Medicare Part B premium)
  • You pay for medical services as you use them in the form of co-pays and coinsurance
  • Unlike Original Medicare (Government), Medicare Advantage plans have an out of pocket maximum cap to protect you against catastrophic spending
  • Some plans include your Prescription Drug Plans. This is also known as “MAPD” Medicare Advantage Prescription Drug plan. The convenience of having your medical and Part D drug benefits rolled into one plan
  • Some plans offer benefits beyond original medicare. Some of these are things like dental, vision, hearing coverage as well a gym membership and over the counter benefits. Limitations, co-payments, and restrictions may apply.

Original Medicare (Government) with a Supplement plan gives you very comprehensive coverage. The primary differences are that with Supplement plans, you can see any doctor that accepts Medicare. You don’t have to ask your doctors if they take your specific Supplement insurance company. The network is Medicare (Government), which has over 800,000 providers. The network is nationwide, not local to Nevada.

Medicare pays 80% and your Supplement plan 20%, leaving you with little out of pocket.

Supplement plans also don’t change their benefits from year to year. This means they don’t require as much homework from you. You won’t have to annually review the upcoming benefit changes like you will on an Advantage plan.

However, Supplement plans do not include Part D coverage (prescription Drug Plan), so you will need to buy a separate Part D policy. They also do not offer any routine dental, vision or hearing while some Medicare Advantage plans includes these benefits.