We get it: Figuring out Medicare, the federal health insurance program for Americans 65 and older, can be confusing. After all, it encompasses several elements. One part of Medicare that many likely do not know much about? Medicare Advantage. This particular plan has its own unique benefits and drawbacks that may make it a better fit for some seniors than others. You may be wondering, “what is Medicare Advantage?” Keep reading to learn more about the health insurance plan, how it differs from Original Medicare and when you can enroll.
What is Medicare Advantage?
While most people have heard of Medicare, Medicare Advantage isn’t as well-known. It’s actually considered Medicare Part C, and it includes the benefits from Original Medicare (Parts A and B), as well as prescription drug coverage (Part D). However, this plan is not offered by the government.
“The major difference is that Medicare Advantage is a private plan,” says Princella Seymour, CEO and founder of Complete Elder Solutions. “It offers more benefits and options and may include services such as vision, hearing, dental, fitness memberships and transportation.”
It’s important to note that there are some drawbacks to this Medicare plan that are not present with the original plans. Network restrictions for providers, limited outside coverage and additional costs are just some roadblocks you may encounter.
“Original Medicare generally offers broader provider access but fewer extra benefits,” she adds.
What does Medicare Advantage cover?
If you’re wondering if Medicare Advantage may be a good fit for you, here’s a look at what the plan encompasses.
A specific network for patients
While Original Medicare allows you to see any doctor or hospital that accepts Medicare, Medicare Advantage does not. Expect to have fewer options when you need care.
“Some plans do offer out-of-network coverage for nonemergency services, but this could well come with a higher cost,” shares Seymour. “With Medicare Advantage, you might need a referral to see a specialist, but with original Medicare, you generally don’t need a referral to see a specialist.”
Limits on out-of-pocket spending
Similar to a deductible, most Medicare Advantage plans have a cap on what you have to pay, Seymour explains. This means there’s a yearly limit on what you need to pay for services covered by Part A and Part B.
“Once that threshold is reached, you pay nothing more for covered services for the rest of the year,” she says.
Lack of additional coverage
“With Medicare Advantage Plans, your Part A and Part B benefits are normally covered in full,” Seymour explains. “However, it will not cover certain costs such as hospice care, clinical trial expenses and other benefits required by law.”
An important note: You can join a Medicare Advantage plan even if you have a pre-existing condition.
Extra perks
Because the plans are offered by private companies, you may find your specific plan includes additional perks, like:
- Over-the-counter drugs
- Gym memberships
- Vision services
- Hearing services
- Dental care
How to enroll in Medical Advantage
In order to join a Medicare Advantage plan, you must first meet the following criteria:
- Have Medicare Part A and B (and have the coverage start dates)
- Live in the service area of the plan you would like to join
- Be a U.S. citizen or legally present in the country
Then you have the ability to enroll in Medicare Part C during the open enrollment period. This is from October 15 to December 7 for those looking to join, switch or drop a Medicare Advantage plan. (Coverage will then begin on January 1 of the following year.)
Once you choose a plan you like via Medicare.gov/plan-compare, simply select “Enroll” for the one you want to join.
Can you switch from Medicare Advantage to Original Medicare?
If you find you aren’t happy with your Medicare Advantage plan, you do have the option to revisit it on an annual basis. During the Medicare Advantage Open Enrollment, which is from January 1 to March 31, anyone already enrolled in a Medicare Advantage Plan can switch to another plan (with or without drug coverage). During this time you can also switch back to Original Medicare and join a separate Part D drug plan.
(Note: This enrollment period is only for those already with Medicare Advantage, not for those looking to join for the first time).
Both types of plans have their pros and cons, so it’s a good idea to figure out what works for your situation.
“It comes down to assessing their health needs, financial situation and personal preferences to determine which plan is best suited for them,” adds Seymour. “I always encourage clients to do their research and even talk to an expert, before committing to a plan.”
