Medicare Advantage
What is Medicare Advantage?
There are two main coverage options for seniors on Medicare. The first option is staying with Original Medicare and then possibly adding a Medicare supplement and/or a prescription drug plan.
Another option is enrolling in a Medicare Advantage plan.
Medicare Advantage is also known as Part C of Medicare. Advantage plans are offered by insurance companies. Enrolling into one of these plans means you are choosing to get your Medicare part A and B benefits from that insurance company instead of Original Medicare.
In addition to part A and B benefits, most plans also include prescription drug coverage. It’s important to know that insurance companies must be approved by Medicare in order to offer these types of plans.
How much does Medicare Advantage cost?
Companies that offer Advantage plans are paid by Medicare to provide you benefits. Which means the monthly premium you pay is often less than a Medicare Supplement plan. In exchange for this premium savings you generally use a network of providers that have contracted with your insurance company.
Typically, HMO plans in Wisconsin have a smaller premium than PPO plans. It’s not uncommon to see HMO plans with premiums of $0 per month. PPO plans may be closer to $50. Some plans even have premiums of over $200 per month.
The monthly premium may not be your only expense. In addition to the monthly premium, these plans may include extra costs you need to cover. These include
- Deductibles which is the amount that you need to pay before the plan pays anything
- Copays for treatment like a set payment every time you see your doctor
- Coinsurance which is a percentage of the costs that you need to pay.
What this means for you is your budget needs to be ready for more costs than just the monthly premium. You could be hit with unexpected out of pocket expenses with a hospital stay, cancer or surgeries.
Unlike Original Medicare, these plans have a limit to the maximum amount you would have to pay for treatment each year. This varies by plan but it’s not uncommon to be near $6,700 for the year. After that the plan would pay 100% so your exposure is limited which is a plus.
HMO VS PPO
HMO is a health maintenance organization.
- Potentially no benefits if you get coverage outside of network
- So if you see a doctor that isn’t in the insurance company’s network you may have to pay the entire cost on your own
- May need a referral from your primary care physician to see a specialist
- These plans usually have lower premiums compared with PPO plans
PPO is a preferred provider organization
- May have benefits outside of network but at a reduced rate
- Insurance company may be something but at a lower rate than what they would pay for you to see a doctor in network
- Usually do not need a referral to see a specialist
- May still have a primary care doctor
- Premiums are typically higher compared with HMO plans
Can I see my own doctor?
Maybe. If your doctor does not accept that specific Advantage plan then you could be responsible for most or all of the costs for treatment. For that reason it’s crucial to choose a plan that your doctor accepts.
But you should be aware that doctors can leave your plan’s network at different times in the year. So just because they are in network in January does not mean they will be for the entire year.
Am I still part of Original Medicare?
As a Medicare Advantage plan member you are still part of Medicare. Because you have a Medicare Advantage plan, you get your Part A and Part B coverage from the insurance company, not from original Medicare. Since you remain a member of Medicare, you must continue to pay your part B premium (and part A if you don’t qualify).
When can I join or leave an Advantage plan?
You can join or leave an Advantage plan during the Annual Enrollment period. This happens once every year and lasts from October 15th to December 7th. Due to specific circumstances you may be able to join or leave a plan at different times throughout the year. If you would like to make a change but aren’t sure if you qualify, I would recommend contacting a local agent.
How do I find a plan?
You must be entitled and enrolled into Medicare Part A & B in order to select a Part C Advantage plan. Many counties in Southern Wisconsin have around 15 different options to choose from.
Medicare.gov has a nice website for a high level overview comparison of plans. Or I’d be happy to help you as an independent agent. I represent many of the companies available in Wisconsin but I work for you.
Before enrolling here are some questions to ask yourself
It’s more complicated than this but here are a few questions to consider as you move forward.
- Is there a doctor that is important for me to be able to see?
- Do I prefer to pay a fixed monthly premium for something I may or may not use? Or would I prefer a lower monthly premium and potentially save money?
- How do I feel about having to pay a copay whenever I need treatment?
- How would I feel about being told I can’t see a certain doctor because I didn’t receive a referral from my primary doctor?
- Do I have specific prescriptions that I need covered?
There are many different plans to choose from. If you would like help looking at them please contact me and I’d be happy to help you.
These plans vary by county so call me to learn more about what’s available in your area.
You can also check out Medicare Supplements
Mike Lovell
608-571-4461