All About Medicare Advantage Plans

Mature lady datingIf you’re looking for a cost-effective insurance option for yourself or a family member, a Medicare Advantage plan may be right for you.

Offered from private, Medicare-approved insurance companies, these policies are a good alternative to Original Medicare. Known as Medicare Part C, these plans include both Medicare Part A and B (hospital and medical insurance), and other extras such as Part D prescription drug coverage, and vision, dental and hearing aids.

Here’s some more information to help you choose the best option.

What is a medicare advantage plan?

The Federal government requires Medicare Advantage plans to offer at least as much coverage as Original Medicare. That means you’ll be able to get hospice care, many new Medicare benefits, access to some clinical trials, and emergency care.

Many policies also provide vision, hearing, and dental insurance along with wellness programs such as gym memberships. Some Medicare Advantage plans will pay for transportation to and from your doctor’s office, adult daycare, healthcare outside the United States, and over-the-counter drugs as well.   

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However, plans may not cover procedures that Medicare doesn’t consider medically necessary. If you need non-emergency medical care, you should check with your insurance provider in advance to make sure that it’s covered.

If your coverage is denied, your provider must notify you in writing, and you can appeal the decision. The rules can vary about whether you need a referral to see a specialist and which doctor visits are covered.

You’ll need to pay a monthly premium for Medicare Part B, and there’s an additional fee for Medicare Advantage. Supplemental Medigap coverage for anything that your Medicare Advantage plan doesn’t cover is available, letting you customize your insurance easily.

Since 2011, federal regulation has required Medicare Advantage plans to provide an out-of-pocket limit for services covered under Parts A and B not to exceed $6,700 (in-network) or $10,000 (in-network and out-of-network combined), according to the Kaiser Family Foundation. In 2021, these maximums may increase.

Who qualifies for medicare advantage?

Anyone who qualifies for Medicare qualifies for a Medicare Advantage plan. To qualify for Medicare, a person must be 65 or older and be a U.S. citizen or a permanent legal resident who has lived in the country for more than five consecutive years.

You or your spouse must also have worked long enough to be eligible for Social Security or railroad retirement benefits. Some government employees don’t pay Social Security taxes while working, but they still pay Medicare payroll taxes.

People younger than 65 can use Medicare Advantage if they receive Social Security disability benefits or a disability pension from the Railroad Retirement Board for more than 24 months. For more information about eligibility requirements, visit Medicare.gov.

Types Of Medicare Advantage Plans

Several types of Medicare Advantage plans are available. Health Maintenance Organization (HMO) policies require people to get non-emergency care from in-network providers. Plans with a point-of-service (POS) option will let you use doctors outside your network for some services. You’ll usually have a primary care doctor that will refer you for any visits to specialists.

Preferred Provider Organization (PPO) plans allow you to use doctors and hospitals that aren’t part of your network, but you’ll have to pay more than when you use in-network physicians.

You won’t need a referral to see a specialist. Special Needs Plans (SNPs) are for people with chronic health problems who live in long-term care facilities or have Medicare and Medicaid coverage.

These plans usually have plenty of specialists in diabetes, kidney failure, heart failure, and other diseases that impact their members, and they’re less costly than HMO or PPO plans. 

To learn more about Medicare Advantage plans and enroll in the best policy for your needs, you need to understand your specific healthcare needs — keeping in mind what your health may look like in the future.

The right Medicare Advantage plan can improve your coverage, reduce costs, and increase your peace of mind.

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Ava Moore
BA, MA Psychology (and Conflict Resolution), University of Cambridge (2007). With a decade of trial and error in psychology and 33 years of navigating my own complex (that's one word for it!) relationships with family, friends, co-workers and men, I hope I have some useful knowledge and skills to share with my readers about making sense of relationships and trying to become a better person every day.

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