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10 Things to Know About Medicare Advantage Plans

If you’re eligible for Medicare, you may be able to enroll in a Medicare Advantage plan offered by a private insurance company. Here are 10 things to know about Medicare Advantage plans.

1. Medicare Advantage plans cover everything Medicare Part A and Part B cover

All Medicare Advantage plans cover what Medicare Part A covers (hospital care) and what Medicare Part B covers (medical care).

For example, if you get the flu shot covered by Medicare Part B, you will also get the flu shot covered by your Medicare Advantage plan. If you get a night in the hospital covered by Medicare Part A, you will also get it covered by your Medicare Advantage plan.

2. Many Medicare Advantage plans have extra benefits

Original Medicare (Part A and Part B) has very limited coverage for prescription drugs you take at home, but most Medicare Advantage plans cover prescription drugs. Medicare Advantage plans may also cover other extra benefits including routine dental, vision, and hearing coverage as well as fitness benefits.

3. Medicare Advantage plans are regulated by Medicare

You are still in the Medicare program with a Medicare Advantage plan, even though your benefits will be administered by a private insurance company. You still have Medicare rights and protections, including the right to appeal a coverage decision.

4. All Medicare Advantage plans have out of pocket maximums

Unlike Original Medicare, all Medicare Advantage plans have caps on how much you will pay out of pocket for your covered medical expenses. The out of pocket maximum resets annually.

5. You may have to pay two premiums with a Medicare Advantage plan

Some Medicare Advantage plans have premiums as low as $0. However, many Medicare Advantage plans have a monthly premium that you must pay in order to be covered by the plan.

In addition to the Medicare Advantage premium, you are also responsible for your Medicare Part B premium which you pay to the government.

6. Most health problems won’t prevent you from getting a Medicare Advantage plan

If you have a pre-existing condition, such as high blood pressure or cancer, this generally won’t prevent you from getting a Medicare Advantage plan.

The only condition that might prevent you from getting a Medicare Advantage plan is end-stage renal disease (ESRD). However, people with ESRD may be able to enroll in a Special Needs Plan, which is a type of Medicare Advantage plan.

7. Many Medicare Advantage plans have networks

Many Medicare Advantage plans are structured as HMOs (Health Maintenance Organizations) or PPOs (Preferred Provider Organizations). Both of these plans generally have networks, which are lists of providers contracted to provide services under the plan. You may be able to use doctors, hospitals, and providers out of network for an additional costs. Sometimes the costs you pay to see providers out of network will not apply towards your out of pocket maximum.

8. You can switch Medicare Advantage plans if you’re not happy with your plan

You can switch Medicare Advantage plans anytime during your Initial Enrollment Period. This is a 7 month period which starts 3 months before you turn 65 or reach your 25th month of disability benefits, includes that month, and extends three months after.

Once your Initial Enrollment Period has passed, you can switch Medicare Advantage plans during the Medicare Open Enrollment Period. The Medicare Open Enrollment Period is October 15 to December 7 every year.

9. Your out-of-pocket costs may be easier to calculate with a Medicare Advantage plan

Medicare Part B generally charges coinsurance for covered services. Coinsurance is a percentage, for example, 20%. However, you might not know if this is 20% of $150, or 20% of $700 until you get the bill.

Medicare Advantage plans usually charge copayments for covered services. A copayment is a set dollar amount, for example, $10 for a visit to a primary care doctor. It might give you peace of mind knowing you will only pay $10 when you visit a primary care doctor versus expecting a bill for an unknown amount.

10. Your Medicare Advantage plan may leave Medicare

Medicare Advantage plans have annual contracts with Medicare and can choose not to renew their contract for the following year. If this happens to you, you will usually have the opportunity to enroll in another Medicare Advantage plan. You also can choose to return to Original Medicare.

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