Comparing Medicare Advantage Plans: What to Look For?
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Choosing the right Medicare Advantage plan is crucial for your healthcare needs. With numerous options available, it’s vital to compare them carefully to find the best fit. Here’s a breakdown of what to consider when comparing Medicare Advantage plans:
Understanding Medicare Advantage Plans
Medicare Advantage plans, also known as Medicare Part C, are offered by private insurance companies approved by Medicare. They combine Part A (hospital insurance) and Part B (medical insurance) coverage into one plan. These plans often include extras like prescription drug coverage (Part D), dental, vision, and hearing services.
Coverage and Benefits
When comparing plans, start by checking the coverage and benefits offered. Beyond hospital and medical coverage, look for additional services such as fitness memberships, transportation, or telehealth. Consider your current and future healthcare needs to decide which benefits matter most to you.
Costs: Premiums, Deductibles, and Co-pays
Cost is a key factor in choosing a Medicare Advantage plan. Compare monthly premiums, deductibles, and co-pays for each plan. Premiums can vary widely, and some plans have $0 premiums, though you still pay your Medicare Part B premium. Look at co-pays for doctor visits, hospital stays, and prescriptions, as these costs can accumulate.
Provider Networks
Most Medicare Advantage plans use provider networks including doctors, hospitals, and healthcare providers who accept the plan’s payment terms. Check if your current providers are in the network. If you have specific doctors or specialists you prefer, make sure they participate to avoid higher costs.
Prescription Drug Coverage
If you take medications, review each plan’s formulary, which lists covered drugs and costs. Compare your current prescriptions with each formulary to ensure coverage. Pay attention to any rules like prior authorization or step therapy that might affect access to medications.
Star Ratings and Customer Reviews
Medicare rates Advantage plans with stars based on factors like member satisfaction and quality of care. Higher star ratings usually mean better performance. Also, read reviews from members to understand their satisfaction with coverage, customer service, and provider network.
Medicare Advantage Resources
Use available resources to compare plans. Visit Medicare’s website or use tools from Medicare Advantage providers to compare costs, benefits, and coverage options. These resources simplify the process of narrowing down your choices.
Enrollment Periods and Plan Changes
Know Medicare Advantage enrollment periods—Initial, Annual, and Special—to enroll, switch, or disenroll. Watch for deadlines and any changes in plan benefits or offerings from year to year.
Considering Your Health Needs and Preferences
The best Medicare Advantage plan depends on your health needs, preferences, and budget. Consider your health status, chronic conditions, expected medical costs, and desired coverage level. Seek advice from Medicare Advantage providers or insurance agents specializing in Medicare for guidance.
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Medicare Advantage Plans
Most Common Types of Medicare Advantage Plans
There are various types of Medicare Advantage plans. The two most frequently used are:
- HMOs (Health Maintenance Organizations). HMOs have closed provider networks and you usually have to get all care within your plan’s network except for emergency services. You choose a primary care doctor (PCP) who manages all of your medical care. These plans often require a referral for specialist care and prior authorization for certain tests and procedures from your PCP. HMO plans almost always include prescription drug coverage (Part D).
- PPOs (Preferred Provider Organizations). PPOs also have provider networks, but you can still go to any provider that takes Medicare. However, your payment is substantially less out-of-pocket, when you stay in the network. You will not need referrals for a specialist and you don’t have to pick a primary care physician (PCP). Most PPO plans also include prescription drug (Part D) coverage.
Other Types of Medicare Advantage Plans
- Private Fee-for-Service (PFFS) Plans. Senior Healthcare Advisors offer Medicare PFFS plans, as a Medicare Advantage Plan. PFFS is a type of Medicare Advantage Plan (Part C) that is not the same as Medigap or Original Medicare. The plan determines how much it will pay hospitals, doctors, and other health care providers, and what your cost is when you get care.
With a PFFS, you do not have to choose a PCP (primary care physician), nor do you need a referral for a specialist. PFFS may cover prescription drugs, however, if your PFFS Plan does not offer prescription drug coverage, you can enroll in a separate Medicare Drug Plan (Part D) to get coverage.
“You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms, agrees to treat you and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services). Not all providers will.” –Medicare.gov. (2022).
- Medicare SNPs are a type of Medicare Advantage Plan (like a PPO or HMO). Medicare SNPs cover only people with specific characteristics or diseases The benefits of Medicare SNPs are tailored to their provider choices and drug formularies that best meet the specific needs of the groups they serve. Sometimes, SNPs cover out-of-network services and some do not. Check with your Senior Healthcare Advisors (855-824-6618| TTY 711) or your plan to see if they cover services out of network, and if so, how it affects your costs. Medicare SNPs normally have specialists in the conditions or diseases that their members are affected by.
Your Costs With Medicare Advantage
Each Medicare Advantage differs, so it’s not easy to give you a snapshot of your costs. Each private company that offers you a plan can decide what to charge you for premiums, copayment amounts, and deductibles.
Some Medicare Advantage plans have what is called a “zero premium”, meaning that it does not add any additional premiums over what you are paying already for Part B.
**You have to have both Medicare Part A and Part B to enroll in a Medicare Advantage plan.**
Costs Breakdown
- To switch to a new Medicare Advantage Plan, simply choose which plan you want to join during one of the enrollment periods. You’ll automatically be disenrolled from your old plan at the start of your new plan’s coverage.
- Unless you have other prescription drug coverage, we suggest that you carefully consider Medicare prescription drug coverage (Part D). Remember, you may only be able to switch at certain times of the year.
Medicare Advantage: Maximum Out of Pocket (MOOP)
Every Medicare Advantage plan must have an out-of-pocket maximum to protect you. Medicare defines the maximum allowable amount for this Out-of-pocket benefit each year.
An important feature of Medicare Advantage plans is the MOOP – maximum out-of-pocket. This limits the medical cost you could be responsible for in a plan year.
Why is this important? For Medicare Advantage (2022), your maximum out-of-pocket limits for in-network services can reach up to $7,550. If you use an out-of-network service, you could have a MOOP of $11,300. Medicare covers only 80% of the cost of your Part A and Part B benefits. This means that you are responsible for the other 20%. 20% can be a great deal of money. For example, if you have a $150, 000.000 hospital bill, you would owe $30,000.00.
When you review a potential Medicare Advantage plan (Part C), look at the MOOP on that plan. Many people ask us to compare Original Medicare vs Medicare Advantage plans. Original Medicare does not have any MOOP to protect you. You could pay that 20% forever. So if you cannot afford the more comprehensive Medigap plans, then a Medicare Advantage plan at least has an MOOP to protect you. For many folks, this makes Medicare Advantage coverage a more attractive option than Original Medicare alone.
