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Medicare Advantage

President Bill Clinton signed the Balanced Budget Act of 1997 into law, which established Medicare Advantage plans. Part C of Medicare is the name for these plans. They’re known as replacement plans in some doctor’s offices; more on that later.


This program was created by Congress to provide Medicare beneficiaries with a less expensive option than Medigap. They also don’t have much Medicare underwriting. This means they’re a coverage option for people who missed the Medigap open enrollment window and are now ineligible for Medigap due to health issues.

Medicare Advantage plans are not the same as Medigap plans, and they are not interchangeable. Instead of using original Medicare, members receive benefits from a private insurance company. As previously stated, they are sometimes referred to as Medicare replacement insurance.


Medicare isn’t fond of this terminology because it isn’t entirely accurate. When you join a Medicare plan, you never replace your Medicare coverage permanently. Instead, you’ve decided to get your benefits from a private company for the remainder of the year. During a valid election period, you can always return to Original Medicare. Read on to learn more about what you need to know about Medicare Advantage.

A Medicare Advantage plan is a private Medicare insurance plan that you can join to receive your Medicare benefits in a different way. Medicare pays the plan a monthly fee to administer your Part A and B benefits when you do. While enrolled in a Medicare Advantage plan, you must continue to be enrolled in both Medicare Parts A and B. Medicare reimburses the Medicare Advantage company for taking on your medical risk. Medicare Advantage plans are funded in this manner.


At the time of treatment, you will show your Advantage plan ID card. Instead of billing Original Medicare, your providers will bill the plan. This is why some providers consider them Medicare replacement plans but keep in mind that you can always switch back to Original Medicare during an annual election period in the future.


Each Advantage plan has its own benefits summary. This summary will show you how much your copays for various healthcare services will be. All of the same services that Original Medicare provides, such as doctor visits, surgeries, lab work, and so on, will be available through your plan.


A visit to a primary care physician could cost you $10. Specialist copays are frequently higher – a $50 copay for a specialist is not uncommon. Diagnostic imaging, hospital stays, and surgeries could all result in higher copays. Copays for these items are typically in the hundreds of dollars. This, however, varies greatly between states, so look into the plans in your area to learn more.


One of the best things about Medicare Advantage plans is that some of them include minor dental, vision, and hearing benefits. A gym membership is included in some plans. When looking for Medicare Advantage plans that include dental and vision coverage, our experts at Boomer Benefits can assist you in comparing the ancillary benefits offered by different carriers.

You agree to follow certain rules in exchange for the lower premiums offered by Advantage plans. Health Maintenance Organization (HMO) or Preferred Provider Organizations (PPO) networks are used by the majority of Medicare Advantage plans.


Except in emergencies, Medicare HMO networks generally require that patients be treated only by network providers. In most cases, you’ll need to choose a primary care physician. If you need to see a specialist, that doctor can arrange for a referral. Some HMO plans include a point-of-service feature that allows you to see out-of-network providers in specific situations.


Although Medicare PPO networks allow you to see doctors outside of the network, you will incur significantly higher out-of-pocket costs. Medicare Private-Fee-for-Service (PFFS) plans are available in a few counties. Part D may or may not be included in these plans. The way you obtain care differs as well. While this plan type was once very popular, it is now being phased out in most areas. More information on Medicare PFFS plans can be found here.

If you’re deciding between Medicare Advantage and Medicare Supplement Plans (Medigap), there are a few things to keep in mind before enrolling.

  • You must be a Medicare Part A and B beneficiary and live in the plan’s service area. Some people believe that by enrolling in Medicare Advantage, they can avoid having to pay for Part B. That is not the case. You will be immediately disenrolled from your Medicare Advantage plan if you drop Part B while enrolled.

  • There is one health question in Medicare Advantage plans: Have you been diagnosed with kidney failure or End-Stage Renal Disease (ESRD)? Starting with plans in 2021, this question will no longer be asked.

  • For the lowest out-of-pocket costs, use network doctors and hospitals. HMO or PPO networks are available in some plans. Except for emergencies, most Medicare HMO plans do not cover anything outside of their network. Visiting a provider outside of a PPO network will result in you spending more money.

  • Some procedures may require prior authorization under advantage plans.

  • On many HMO plans, you may need a referral from your primary care physician before seeing a specialist.

  • Keep your Medicare card, which is red, white, and blue, in a safe place. Don’t give it to any of your medical professionals. If they send bills to Medicare, they will be rejected because they should have been sent to your Medicare Advantage insurance company for processing. 


Your Medicare Advantage plan must be billed by your providers. When people sign up for Medicare Advantage plans, they are agreeing to be covered by the plan instead of Original Medicare for the rest of the calendar year.

There are lock-in periods for Medicare Advantage plans. When you turn 65, you can enroll in one during the Initial Enrollment Period. After that, you can only enroll or disenroll at specific times of the year. You must remain enrolled in Medicare Advantage for the remainder of the calendar year once you enroll. Unless you qualify for a special enrollment period due to a specific circumstance, you can only disenroll from an Advantage plan at certain times of the year.


The most common time to switch your Medicare Advantage plan is during the Annual Election Period in the fall. Each fall, this period runs from October 15th to December 7th. Your enrollment changes will take effect on January 1st. You must notify your Medicare Advantage plan carrier if you decide to leave your Medicare Advantage plan and return to Original Medicare. Otherwise, Medicare will continue to show you as a member of an Advantage plan rather than Medicare.

Some people enroll in Medicare Advantage plans without first researching how they work or speaking with a knowledgeable agent. As a result, they are unaware of all of the rules. They may be forced to enroll in a plan that their doctor refuses to accept or that does not cover one of their medications. This occurs most frequently in January, after a person has enrolled in a Medicare Advantage plan during the Annual Election Period.


Congress created the Medicare Advantage Open Enrollment Period, which runs from January 1st to March 31st each year, for this reason. You can disenroll from any Medicare Advantage plan and return to Original Medicare during this time. You will be able to add a separate Part D drug plan to your plan.


Unfortunately, this does not guarantee that you will be able to return to your previous Medigap plan. To get re-approved for Medigap, you will usually have to answer health questions and go through medical underwriting, unless this is your first time in a Medicare Advantage plan. Before switching from a Medigap plan to Medicare Advantage, think about this.


You can also switch from your current Medicare Advantage plan to a different Medicare Advantage plan during the Medicare Advantage Open Enrollment Period. Please keep in mind that you can only use this time frame once a year.

Congress intended for these plans to provide you with options for accessing your Medicare benefits. The following are some of the reasons why people might choose an Advantage plan:

  • You pay for medical services as you use them in the form of copays and coinsurance.

  • Many plans have low monthly premiums (although you must continue to pay your Medicare Part B premium).

  • In contrast to Original Medicare, Medicare Advantage plans have an out-of-pocket maximum cap to protect you from unexpected costs.

  • Having your medical and Part D drug benefits rolled into one plan saves you time and money.

  • Some plans may include benefits such as vision coverage that is limited.

  • There may be limitations, copayments, and restrictions. 


Remember, there are no right or wrong answers; it’s a personal decision. Based on your own knowledge of your medical usage, weigh the benefits of Original Medicare vs. Medicare Advantage.

Original Medicare, combined with a Medicare Supplement (Medigap) plan, provides comprehensive coverage without a doubt. The main distinction is that with Medigap plans, you can visit any Medicare-accepting doctor. You don’t need to check with your doctors to see if they accept your Medigap plan. Medicare is the network, and it has over 1 million contracted providers all over the country.


On the back end of some Medigap plans, there is more coverage. Depending on which Medigap plan you select, Medicare will pay 80% and your Medigap plan will pay some or all of the remaining 20%. You will have a small out-of-pocket expense as a result. A beneficiary with a Medigap Plan G, for example, will not be subjected to the recurring copays at the doctor that a Medicare Advantage plan might entail.


Part D coverage is not included in Medigap plans, so you’ll have to purchase it separately. They also don’t provide routine dental, vision, or hearing services, whereas some Medicare Advantage plans do. There is no right or wrong decision. Simply put, the two types of insurance work in different ways. Choose the option that best suits your needs.

Before joining a plan, keep the following considerations in mind:

  • Advantage plans aren’t accepted by all hospitals and doctors. We can help you determine whether your medical providers accept the plan you are considering.

  • Every year, the benefits of an Advantage plan may change. Your Part C insurance company will send you a packet in September informing you of the changes. On January 1 of each year, the plan’s benefits, formulary, pharmacy network, provider network, premium, and/or co-payments and co-insurance may change. Will you review your annual packet and communicate with your agent if you have any questions or concerns about the changes?

  • In most cases, your enrollment is for the entire year. You can only opt-out of an Advantage plan at specific times of the year. Unless you qualify for a special election period, if you decide in April that you don’t like the plan, you’ll have to wait until the next annual election period begins in October to change it.

  • If you sign up for one at the age of 65, you must be certain that you want to keep the coverage long-term. Your open enrollment period for a Medigap plan with no health questions expires six months after your Part B coverage begins. If you have health problems, you might not be able to get a Medigap plan later because it will require you to answer medical questions. If you are not healthy enough to qualify for Medigap at that point, you may be denied coverage.

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Next Steps

People frequently ask which Medicare Advantage plan is the best when in reality it depends on a variety of personal factors. What works for a friend or neighbor might not work for you. Our Medicare-certified agents are happy to help talk through your personal factors and Medicare Advantage plans that may work for you. If you’re interested in discussing these plans and what will work best for you, contact us or schedule an appointment using our online booking system.

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