When considering health coverage as a senior, it’s important to weigh the pros and cons of Original Medicare versus Medicare Advantage. While Original Medicare gives you more flexibility to see any doctor who accepts Medicare, Medicare Advantage can provide extra coverage and simplify billing in some cases. This article will explore the key factors to consider when deciding whether a Medicare Advantage Plan is a good fit for your needs or if traditional Medicare may be a better choice. We’ll discuss the differences in coverage, costs, provider networks and other important aspects to help you make the right choice.

What is Medicare Advantage?

Medicare Advantage, also known as Medicare Part C or MA, is a type of health insurance plan that is offered by private insurance companies that contract with Medicare. It provides all the benefits of Original Medicare (Part A and Part B), which covers hospital and medical services, as well as additional benefits that Original Medicare does not cover, such as prescription drug coverage (Part D), dental, vision, hearing, and wellness programs. Some plans may also include extra perks, such as gym memberships, transportation, or over-the-counter items.

Medicare Advantage Plans are available in different types, such as Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-for-Service (PFFS), Special Needs Plan (SNP), or Medical Savings Account (MSA). Each type of plan has different rules and costs, depending on the network of providers, the level of coverage, and the services offered.

To enroll in a Medicare Advantage Plan, you must be eligible for Medicare and live in the service area of the plan. You must also continue to pay your Medicare Part B premium, which is $148.50 per month in 2021, plus any additional premium that the plan may charge. You can join or switch between Medicare Advantage Plans during the annual Medicare open enrollment period, which runs from October 15 to December 7 each year.

How does Medicare Advantage differ from Original Medicare?

Medicare Advantage differs from Original Medicare in several ways:

  • Network: A Medicare Advantage Plan has a network of doctors and hospitals that are contracted with the plan. You may have to pay more or get less coverage if you go out-of-network, unless it is an emergency. Original Medicare does not have a network; you can see any doctor or hospital that accepts Medicare.
  • Referrals: A Medicare Advantage Plan may require you to get a referral from your primary care provider (PCP) to see a specialist or get certain services. Original Medicare does not require referrals; you can see any specialist or get any service that is approved by Medicare.
  • Prior authorization: A Medicare Advantage Plan may require you to get prior authorization from the plan before getting certain tests, procedures, or treatments. This means that the plan has to approve the service before it will pay for it. Original Medicare does not require prior authorization; you can get any service that is approved by Medicare without needing approval from anyone.
  • Out-of-pocket costs: A Medicare Advantage Plan has a limit on how much you have to pay out-of-pocket each year for your health care services. This limit varies by plan, but it cannot be more than $7,550 in 2021. Once you reach this limit, the plan pays 100% of your covered costs for the rest of the year. Original Medicare does not have an out-of-pocket limit; you have to pay 20% of the cost of most services after you meet your deductible, which is $203 for Part B in 2021. You can buy a supplemental insurance policy (Medigap) to help cover some of these costs, but it will cost you an extra premium.
  • Prescription drug coverage: A Medicare Advantage Plan usually includes prescription drug coverage as part of the plan. You do not need to buy a separate Part D Plan to get this benefit. Original Medicare does not include prescription drug coverage; you have to buy a separate Part D Plan if you want this benefit.

What are the pros and cons of Medicare Advantage Plan?

Medicare Advantage has some advantages and disadvantages that you should consider before enrolling in one. Here are some of the pros and cons of this option:

Pros

  • You get more benefits than Original Medicare, such as prescription drug coverage, dental, vision, hearing, and wellness programs
  • You pay less out-of-pocket costs than Original Medicare, as long as you stay in-network and follow the plan’s rules
  • You have a limit on how much you have to pay out-of-pocket each year, which protects you from high medical bills
  • You may get extra perks, such as gym memberships, transportation, or over-the-counter items

Cons

  • You have less choice and flexibility than Original Medicare, as you have to use the plan’s network of providers and get referrals and prior authorization for some services
  • You may have to pay more or get less coverage if you go out-of-network, unless it is an emergency
  • You may have to deal with more paperwork and bureaucracy than Original Medicare, as you have to follow the plan’s rules and procedures
  • You may have to switch plans or providers if your plan changes its network, benefits, or costs from year to year

How to choose the best Medicare Advantage Health Insurance plan for your needs?

Choosing the best Medicare Advantage Plan for your needs depends on several factors, such as:

  • Your health care needs and preferences
  • Your budget and income
  • Your location and availability of plans
  • Your satisfaction and experience with your current plan or provider

Here are some tips on how to compare and choose the best plan for your needs:

  • Compare the benefits, costs, and networks of different plans available in your area. You can use the [Medicare Plan Finder tool] on the official Medicare website to do this.
  • Check if the plan covers your preferred doctors, hospitals, pharmacies, and medications. You can call the plan or visit its website to find out this information.
  • Read the plan’s summary of benefits and evidence of coverage documents carefully. These documents explain what the plan covers, what it does not cover, what you have to pay, and what your rights and responsibilities are.
  • Talk to your doctor or other health care providers about which plan they recommend or accept. They may have experience with different plans and can advise you on which one suits your needs best.
  • Talk to other people who are enrolled in Medicare Advantage Plans or who have switched between plans. They may have feedback or advice on which plan they like or dislike and why.
  • Review your plan options every year during the open enrollment period. Plans may change their benefits, costs, and networks from year to year, so you may want to switch to a different plan that meets your needs better.

Conclusion

Medicare Advantage is a good option for some people who are eligible for Medicare, but not for everyone. It offers more benefits and lower costs than Original Medicare, but it also has less choice and flexibility. You should weigh the pros and cons of this option carefully before enrolling in one. You should also compare different plans and providers to find the best fit for your needs.

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FAQS

What is the difference between Original Medicare and a Medicare Advantage Plan?

Original or traditional Medicare is a fee-for-service health plan run by the federal government, while Medicare Advantage Plans are run by private insurers approved by Medicare.

2. What are some potential cons of Medicare Advantage Plans?

Disadvantages for Medicare beneficiaries may include more limited provider choices, need for referrals, and less flexibility to switch plans during certain periods compared to Original Medicare.

3. How does coverage differ between Original Medicare and Medicare Advantage Plans?

Original Medicare has no networks but you may pay more per service. Medicare Advantage Plans also have networks but may have lower out-of-pocket costs in-network.

4. What type of plans are available under Medicare Advantage?

Common types include Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO) plans, Private Fee-For-Service (PFFS) plans and Special Needs Plans (SNPs).

5. What does Medicare Part C refer to?

Medicare Part C, also called Medicare Advantage, refers to the alternative to Original Medicare run by private insurers that contract with Medicare to provide all Medicare Part A and Part B benefits.

6. How can I get help choosing a Medicare Plan?

Contact your State Health Insurance Assistance Program (SHIP) for free, personalized counseling on Medicare choices in your state. SHIP counselors are independent of any insurance plans.

7. What benefits do some Medicare Advantage Plans offer that Original Medicare doesn’t?

Some Medicare Advantage Plans may offer additional benefits like vision, dental or health and wellness programs that aren’t covered by Original Medicare.

8. How do I switch from a Medicare Advantage Plan back to Original Medicare?

You can elect to disenroll from your Medicare Advantage Plan and return to Original Medicare during the Medicare Open Enrollment Period each year.

9. What is the difference between a Medicare Supplement and a Medicare Advantage Plan?

Medicare Supplement Plans or medigap Plan help cover some of the gaps in Original Medicare. Medicare Advantage Plans replace Original Medicare coverage entirely.

10. How can I get information about the Medicare Advantage Plans available in my area?

Visit www.medicare.gov and use their Plan Finder tool to compare the costs and coverage of Medicare Advantage and Part D prescription drug plans available where you live.

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