Medicare Advantage
Frequently Asked Questions
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Do you have to pay the Part B premium with Medicare Advantage?
Yes, you must be enrolled in both Parts A and B to qualify for an Advantage plan, regardless of any $0 premium offers.
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How can some Medicare Advantage plans have no premiums?
While some Advantage plans advertise $0 premiums, you’ll still pay the Part B premium and any applicable deductibles, copays, or coinsurance.
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What is a MAPD?
A MAPD is a Medicare Advantage plan that includes drug coverage. Plans without drug coverage are simply called MA.
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How does Medicare Advantage Function?
When you enroll in a Medicare Advantage plan (Part C), you choose to receive your Medicare benefits through a private insurance provider rather than through Original Medicare.​​​​​
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​​​​​Am I limited to a specific network?
Advantage plans typically operate within specific network areas, which can vary in their strictness based on the type of plan.
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Key Takeaways
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You must still pay the Medicare Part B premium even with an Advantage plan.
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Most Advantage plans include Part D coverage, known as MAPD plans, or “all-in-one” plans.
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Understand the differences between Advantage plans, Original Medicare, and Medigap to make an informed decision.
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Enrollment Periods
There are various times throughout the year when you can enroll in an Advantage plan, including your Initial Enrollment Period and the Annual Election Period.
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Understanding Medicare Advantage
Medicare Advantage plans, also known as MA plans, offer an alternative way to receive your Part A and B benefits through a private insurer. Medicare pays these plans a monthly fee to manage your benefits.
While enrolled in an Advantage plan, you must remain enrolled in Medicare Part A and B. Providers will bill your Advantage plan directly, and it’s important to remember that you can switch back to Original Medicare during designated election periods.
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Benefits of Medicare Advantage Plans
Each plan has a unique summary of benefits, detailing copays for various services. Generally, these plans cover the same services as Original Medicare, including doctor visits and surgeries.
Copays can vary, for example, primary care visit is usually less expensive specialist. Higher copays may apply for hospital stays or diagnostic imaging, so it’s crucial to review the specific plans available in your area.
Some Advantage plans may also offer additional benefits.
Medicare Advantage Networks
In exchange for lower premiums, you must follow certain rules with Advantage plans. Most utilize HMO or PPO networks.
HMO networks generally require you to use network providers, except in emergencies, and may necessitate a primary care physician for referrals. HMO plans account for almost 3 quarters of all Medicare Advantage options.
PPO networks allow out-of-network visits, but expect higher out-of-pocket costs.
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Key Rules of Medicare Advantage
If you're considering switching to Medicare Advantage from Medigap, keep these essential rules in mind:
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You must be enrolled in Medicare Parts A and B and reside in the plan's service area.
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Use network providers for the lowest costs; most HMO plans do not cover out-of-network services except in emergencies.
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Certain procedures may require prior authorization.
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For many HMO plans, a referral from your primary care physician is necessary before seeing a specialist.
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Keep your Medicare card secure; do not give it to your providers. Claims should go to your Medicare Advantage plan.
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Enrollment Periods for Medicare Advantage
Enrollment in Medicare Advantage is restricted to specific periods. You can enroll during your Initial Enrollment Period when you turn 65. After that, you can only make changes during designated times throughout the year, including the Annual Election Period from October 15 to December 7, with changes effective January 1.
If you decide to leave your Medicare Advantage plan and return to Original Medicare, it's vital to notify your Advantage plan provider to avoid confusion.
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Medicare vs. Medicare Advantage
Medicare Advantage plans were established under the Balanced Budget Act of 1997 and signed into law by President Bill Clinton. These plans are often referred to as Medicare Part C or replacement plans, though the latter term can be misleading.
Congress designed Medicare Advantage to give beneficiaries more choices for accessing their Medicare benefits. Key reasons to choose an Advantage plan include:
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Many offer low monthly premiums (though you must still pay the Medicare Part B premium).
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You pay for services as needed through copays and coinsurance.
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Unlike Original Medicare, Advantage plans have an out-of-pocket maximum to protect against excessive costs.
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Convenience of combined medical and Part D drug coverage in one plan.
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Medigap vs. Medicare Advantage
Congress created Medicare Advantage to provide Medicare beneficiaries with a more affordable option than Medigap, particularly for those who may have missed their Medigap enrollment period or have health conditions that prevent them from qualifying for Medigap.
Original Medicare with a Medigap plan provides extensive coverage, allowing you to see any doctor accepting Medicare without worrying about specific Medigap provider networks. Medigap generally covers a significant portion of out-of-pocket expenses.
However, Medigap plans do not include Part D coverage, necessitating a separate policy.
Other Considerations
Before choosing a Medicare Advantage plan, consider the following:
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Not all healthcare providers accept Advantage plans. Check with your agent to confirm acceptance.
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Benefits may change annually; you will receive updates from your insurer in September.
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Enrollment usually lasts a year; if you're dissatisfied, you may need to wait until the next Annual Election Period to switch.
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If you enroll in an Advantage plan right after turning 65, be mindful of your Medigap open enrollment window, as it lasts only six months after your Part B effective date.
Conclusion
Choosing the right Medicare Advantage plan depends on various personal factors. What works for someone else may not suit your needs. Avoid making hasty decisions regarding your health insurance. Consult with an experienced agent to explore your options thoroughly.
Contact Medicare Advisor Hub today at (833) 585-2450! We work with numerous carriers, and we are ready to assist you.​