Medicare beneficiaries in traditional Medicare can visit any physician that accepts Medicare; Medicare Advantage plans offer supplemental benefits and charge different premiums and cost-sharing amounts for them.
By 2022, most counties had access to at least one plan that provided additional benefits, such as fitness training, telehealth monitoring and hearing protection (Figure 3).
Many Medicare Advantage plans require enrollees to use providers within their network and limit out-of-pocket expenses during each coverage year.
Eligibility
Medicare Advantage plans offer an alternative to traditional Medicare. They require individuals to pay both a monthly premium as well as any applicable copayments or coinsurances, which provide wider coverage – though not all plans offer equal benefits.
One can qualify to enroll in a Medicare Advantage plan if he or she currently qualifies for Medicare Part A and enrolls, is in an area offering coverage, has valid Social Security or Railroad Retirement Board numbers, and lives near an area offering such plans. A person living with end-stage renal disease (ESRD) does not qualify.
People living with severe, chronic, or disabling conditions may qualify for special additional benefits under Medicare Advantage Special Needs Plans (SNPs). Such benefits could include help with bathing and dressing needs, assistance with meal preparation and transportation to doctor’s appointments.
As part of their Medicare Advantage plans, federal law permits many Medicare Advantage plans to offer additional benefits like fitness club memberships, home health services and telehealth services. Most plans offer these extras; their scope varies from plan to plan. Summit County in Ohio boasted the highest concentration of plans with additional benefits in 2022 with 82 plans providing extras.
Individuals typically can join or leave Medicare Advantage plans during an enrollment period – the Medicare Initial Coverage Election Period runs from three months before an individual turns 65 until his or her birthday month.
Other Medicare Advantage enrollment periods for people losing job-based insurance include a one-month Special Enrollment Period for them and an eight-month Part B Special Enrollment Period that starts one month after they cease working or cease being covered under their employer’s group health plan.
Individuals who miss these enrollment periods may still enroll in Part B and premium Part A during a Special Enrollment Period; however, they may incur a late enrollment penalty fee.
Extra Benefits
Seniors often opt for Medicare Advantage plans (or Part C), known as Part C plans. These offer additional benefits not available through original Medicare, such as fitness classes and meal delivery to maintain a healthier lifestyle; or covering things such as acupuncture or dental care services.
As mentioned in this article on Harcourt Health, Medicare Advantage plans are governed by federal rules, but individual insurance providers can vary the supplemental benefits and premiums they charge in different service areas – meaning you could find yourself with very different coverage from plan to plan.
Typically, the more flexible your provider network is, the lower your out-of-pocket expenses will be. Most MA plans only permit use of providers from within their network; however, there may be exceptions where certain plans reimburse some or all costs of out-of-network services.
However, there are exceptions. Certain Medicare Advantage plans provide greater flexibility than others. Plans such as point of service (POS) and PPOs usually allow more choices when choosing providers than HMOs do – although their monthly premiums tend to be higher due to reduced out-of-network provider costs.
Medicare Advantage’s primary advantage is providing one monthly payment that covers hospital and doctor services; although this may help your budget, it’s essential to assess whether Medicare Advantage is suitable for you; if you have serious health concerns or desire greater control of medical costs, original Medicare may be better suited.
If you opt for a Medicare Advantage plan, switching back to traditional Medicare may be possible within the open enrollment period that surrounds your 65th birthday, or at any other time during the year – however disenrolling from it will increase your Part B premium by 25 percent annually.
AARP’s Medicare Decisions 2022 guide offers more detailed advice about making informed choices when selecting Medicare options that suit your personal needs. In combination with its accompanying app and other resources available online, this publication can assist in helping make informed decisions for future health care needs.
Coverage Options
First step to selecting Medicare Advantage plans that best suits your needs involves understanding its six types and differences – all available on Medicare’s website.
HMO plans are among the most sought-after Medicare Advantage plans, often requiring you to select a primary care doctor who directs your healthcare and refers to specialists when necessary. You’ll usually pay less when using providers within your HMO network; though out-of-network providers are covered at higher costs.
Preferred provider organizations (PPOs) allow more choice when it comes to selecting doctors and hospitals, but similar to HMOs you pay more when using out-of-network providers. Medicare Advantage plans must make their network lists available but you should check with current providers to see if they’re listed before deciding whether or not enrolling.
Private fee-for-service plans typically do not impose network restrictions, although you cannot assume your provider will accept its terms and conditions. Depending on the plan you select, out-of-network services could incur extra charges or you might even not be allowed to access them at all.
Medicare Advantage plans typically provide additional coverage that Original Medicare does not, such as fitness programs, transportation to medical appointments and home aids such as bathroom safety devices or meal delivery services. Furthermore, some plans also provide prescription drug coverage.
Certain Medicare Advantage plans provide additional benefits to specific groups with specific medical or financial needs, known as special needs plans. Unfortunately, they’re not open to all.
If you need help choosing a Medicare Advantage plan that’s best suited for you, speaking to a neutral advisor may be beneficial. There are free resources such as your state’s health insurance assistance program that offer benefits counseling; alternatively you may work with a broker who will offer guidance and recommend one which meets your individual needs.
Costs
Medicare Advantage plans involve several cost components for beneficiaries to enroll, such as enrollment fees, premiums, deductibles, copayments and coinsurance payments. Out-of-pocket costs vary based on which plan is selected as well as which services and providers are utilized frequently and frequently used by beneficiaries.
Individual Medicare Advantage plans offer a range of choices to cater to enrollees’ diverse health and social needs. These options include Health Maintenance Organizations (HMOs), which typically limit coverage to in-network providers. Preferred Provider Organizations (PPOs) provide access to both in-network and out-of-network providers. Special Needs Plans (SNPs) tailor benefits to individuals with specific health or social requirements, such as kidney disease or spinal cord injuries.
SNPs are designed to address the unique needs of people living with chronic conditions or disabilities. These plans offer benefits specifically tailored to serve individuals with conditions like kidney disease or spinal cord injuries. SNPs aim to provide comprehensive coverage and support for those facing specific health challenges.
Overall, Medicare Advantage plans present a variety of options that allow individuals to choose the plan that best aligns with their specific health or social needs. Whether it’s through HMOs, PPOs, or SNPs, Medicare Advantage plans offer flexibility and tailored benefits to enhance the overall healthcare experience for enrollees.
Medicare Advantage plans typically have lower out-of-pocket costs than traditional Medicare because most enrollees utilize services from in-network providers, while out-of-network services could increase your bill significantly. Furthermore, more Medicare Advantage plans are offering additional services and benefits that might not be necessary or beneficial to all enrollees such as wellness visits, telehealth services or fitness benefits that could increase overall costs; to make an informed decision you must weigh each option carefully.
According to the Centers for Medicare & Medicaid Services, total Medicare Advantage spending averaged about 2% more than Original Medicare when comparing plan costs directly against traditional Medicare in 2022 on an apples-to-apples basis in each area; this could be partially explained by enrollees of Medicare Advantage plans being more likely to purchase supplemental coverage such as private Medigap policies than those who don’t enroll.
KFF data indicates that most Medicare Advantage plans offer additional supplementary benefits such as vision and hearing care, dental care, transportation for non-medical purposes and meal assistance programs to their enrollees. A large majority of enrollees in SNPs (more so than individual plans) have access to over-the-counter drugs (96%), transportation benefits (84%), meal assistance programs (79%) and home safety devices or telemonitoring services (25%).