What is Medicare Advantage (Part C)?

How you decide to get Medicare will affect how much you pay in premiums, what benefits and services will be available to you, and which doctors and hospitals are available to you. There are two ways you can choose your Medicare coverage. You can get Original Medicare with or without Medicare Supplement, or you can sign up for a Medicare Advantage Plan. What’s the difference?

To put it simply, Medicare Advantage Plans are Medicare plans that are bundled to include additional benefits. Medicare Advantage, also known as Medicare “Part C”, is a type of Medicare plan that is usually bundled to include not only the usual coverage of Original Medicare, but often includes Medicare drug coverage (part D) and additional benefits as part of the package. This means that with Medicare Advantage, you will be eligible for extra benefits that you otherwise would not be able to get with Original Medicare.

What are the differences between Original Medicare and Medicare Advantage Plans?

• Medicare Advantage Plans often include Medicare Part D. Part D is the part of Medicare that covers prescription drugs. Most Medicare Advantage Plans include Part D, whereas with Original Medicare, it is often an add-on that you can pay to include as part of your plan. It is also important to note that with Medicare Part D, you may need to get approval from your provider for your plan to cover the costs of certain drugs or services. If there is a medication your health requires, it is best to ensure that it will be covered before signing up for a plan.
• Medicare Advantage Plans often include additional benefits. These benefits usually cover services not covered by Original Medicare, including certain vision, dental and hearing services. These types of benefits can also be added to your Original Medicare plan as supplemental coverage. Additional benefits that can be offered by your Medicare Advantage Plans include gym memberships, flex cards, debit cards for over-the-counter supplies, reduced cost-sharing, flex cards, and more.
• Medicare Advantage Plans only cover services from doctors that are in-network. Alternatively, any doctor or hospital in the U.S. that accepts Medicare can see you on Original Medicare, no matter what state you live in. If you have a doctor that you prefer, this may be something you consider as you shop for a Medicare plan.
• Medicare Advantage Plans may have lower or higher out-of-pocket costs. With Original Medicare, you usually pay 20% of the Medicare-approved amount, referred to as a coinsurance, that usually takes effect after your deductible is met. With Medicare Advantage, your out-of-pocket costs can vary, and can be lower or higher for certain services.
• Medicare Advantage Plans may have an additional premium. Medicare Part B, known as medical insurance, has an inherent premium that is present for both Original Medicare and Medicare Advantage. However, Medicare Advantage may have an additional cost added to the premium as part of the plan. However, some Advantage plans may have a $0 premium and even may cover the cost of the Part B premium.
• Original Medicare offers supplemental coverage. Many people with Original Medicare choose to purchase a Medigap (Medicare Supplement Insurance) policy to help cover out-of-pocket costs like copayments, coinsurance, and deductibles. Medicare Advantage Plans, on the other hand, do not work with Medigap policies, as they already have built-in cost-sharing limits and additional benefits.

How do Medicare Advantage Plans work?

Medicare Advantage Plans are offered and provided by private companies. These companies receive a fixed amount of money from Medicare to cover some of the cost of your coverage each month. Companies that offer Medicare Advantage are also required to follow rules set by Medicare, but can have different rules for how you receive services. For example, your Medicare Advantage Plan may require that you get a referral for a specialist, or may require specific facilities or doctors for non-emergency services. Your Medicare Advantage Plan can also charge different out-of-pocket costs.

Rules set by Original Medicare and Medicare Advantage can change each year. Each are required to notify you about any changes before the start of the next enrollment period. Notice is often mailed to you before open enrollment starts, so that if you are impacted by any changes in rules, you may make educated decisions in the upcoming enrollment period.

Should I enroll for Medicare or Medicare Advantage?

Truthfully, this largely depends on your health needs. You know yourself better than anyone, so it’s important to prioritize what you need and weigh the differences between plans. You may need a lower premium, you may need coverage for your prescriptions, or you may just want to continue to go to the doctor you’ve been going to for years. No matter what your health needs are, there is a plan that will offer the coverage needed.

Choose Original Medicare if:

1. Provider Flexibility is Important: If you want the freedom to see any doctor or specialist who accepts Medicare anywhere in the U.S., Original Medicare may be a better fit. There are no network restrictions.
2. You Prefer Simple Cost Sharing: Original Medicare has standardized cost-sharing, like deductibles and coinsurance. However, it’s important to note that while you can purchase a Medigap (Medicare Supplement) policy to help cover these out-of-pocket costs, Medigap plans can be quite expensive. The premiums for Medigap policies tend to increase each year, and they are currently rising at a higher rate than ever before. This means that while Medigap can provide predictable healthcare expenses, it can also become a significant financial burden over time, especially as premiums continue to escalate.
3. You Don’t Need Extra Benefits: If you don’t need additional benefits like vision, dental, or hearing coverage, and are comfortable with separate plans for things like prescription drugs (Part D), Original Medicare might suit you better.

You should carefully consider this emphasis on the rising cost of Medigap plans, especially if you’re planning for the long term and want to manage your healthcare expenses effectively.

Choose a Medicare Advantage Plan if:

1. You Want Additional Benefits: If you’re looking for a plan that includes extra benefits like prescription drug coverage, dental, vision, hearing, or wellness programs, a Medicare Advantage Plan could be more convenient and cost-effective.
2. Cost Control is a Priority: Medicare Advantage Plans typically have an out-of-pocket maximum, which can protect you from very high medical expenses. Some plans may have lower or $0 premiums, though you’ll still need to pay your Part B premium.
3. You Don’t Mind Network Restrictions: If you’re okay with using a network of doctors and hospitals and possibly needing referrals to see specialists, Medicare Advantage could be a good option. This may be particularly appealing if you don’t travel often and mainly receive care in your local area.

Other Considerations:

• Health Status: If you have specific health needs or chronic conditions, consider which plan will provide the best access to the care you need.
• Financial Situation: Compare the overall costs, including premiums, out-of-pocket expenses, and potential savings on prescriptions and other benefits.
• Long-Term Considerations: Consider how your healthcare needs might change over time and whether the plan you choose will continue to meet your needs.

Ultimately, the best choice depends on your individual situation. It can be helpful to compare specific plans available in your area, review what each plan covers, and consider your healthcare priorities before making a decision. It’s also important to keep in mind that you can never plan on an accident, so ensuring that your coverage in case of an emergency is very wise in any case. At the end of the day, there are experts you can speak to who will know what is available to you. By filling out the form HERE, or calling the associated phone number, you could speak to a licensed agent about your health needs, and they can find a plan that best fits you.