9 Medicare Advantage Facts You Should Know

If you qualify for Original Medicare, you may be eligible for a Medicare Advantage coverage, available from private insurers. Like anything else, the more you know about Medicare Advantage plans, the better your chances of maximizing your benefit from them. 

Health has published informative reviews of the best Medicare Advantage plans. Here’s a look at the main facts about Medicare Advantage plans you should know before you sign on the dotted line with the insurance company.

  1. They Cover Everything Original Medicare Does

Original Medicare consists of Medicare Part A for inpatient/hospital care and Medicare Part B for outpatient/medical care. All Medicare Advantage plans address the same things that Original Medicare does. 

So, if your flu shot qualifies for Medicare Part B coverage, it also falls under the umbrella of a Medicare Advantage plan. If Medicare Part A takes care of your hospital stays, so does Medicare Advantage.

  1. Many Have Additional Benefits

Medicare Part A and Part B provide very restricted coverage for prescription medication required for use at home. Most Medicare Advantage plans, however, cater to the costs of prescription drugs. The plans may also take care of routine vision, hearing and dental expenses in addition to fitness benefits.

  1. Plans Are Regulated by Medicare

Medicare Advantage plans may offer coverage that goes beyond Original Medicare, but they are still regulated by the Medicare program. Just because they are administered by private insurers doesn’t imply the insurance company can do as it pleases. You enjoy rights and protections derived from Medicare including your right to appeal coverage decisions.

  1. There are Out-of-Pocket Maximums

Original Medicare doesn’t have out-of-pocket maximums, but Medicare Advantage does. There are caps on the amount of money you can pay for medical expenses out of pocket. This maximum resets each year.

  1. You May Be Required to Pay Two Premiums

Medicare Advantage plans have premiums starting from $0. But plans with $0 premiums are rare. Most have a monthly premium that must be paid, if you want to stay covered. Medicare Advantage plan premiums do not exempt you from paying Medicare Part B premiums to the government.

  1. Preexisting Conditions Unlikely to Disqualify You

Preexisting conditions are one of the hot-button issues of health insurance. They are a key reason for the establishment of Original Medicare. If you have a preexisting illness such as cancer or high blood pressure, that will not ban you from signing up for a Medicare Advantage plan. 

The only condition that could limit your access to Medicare Advantage is end-stage renal disease (ESRD). Still, individuals with ESRD may be allowed to enroll for a special type of Medicare Advantage plan referred to as a Special Needs Plan.

  1. They Have Networks

Medicare Advantage plans are often structured as preferred provider organizations (PPOs) or health maintenance organizations (HMOs). These plans have networks that list healthcare providers mandated to provide medical services to members of the plan. 

You may still use doctors, providers and hospitals outside the Medicare Advantage plan’s network but you will incur an extra cost for this. Sometimes, the money you pay in order to see a non-network provider will not count toward your annual out-of-pocket cap.

  1. You Can Change Plans

You aren’t locked into any Medicare Advantage plan for life. As an acknowledgement that people will choose a plan without fully knowing whether it’s the best for them, Medicare allows you to switch plans. 

This can occur within your initial seven month enrollment period. Once the enrollment period has ended, you can still switch plans during the Open Enrollment Window each year.

  1. The Plan Can Disengage from Medicare

Medicare Advantage plans are offered by private insurance companies. So, companies will only offer the plan for as long as it makes financial sense to them. Medicare Advantage plans are governed by an annual contract that insurers renew with Medicare each year. 

There’s no obligation for the plan to renew, however, so there is always the possibility that it could be removed from Medicare. If your plan opts to disengage, you can either switch to another Medicare Advantage plan or return to Medicare Part A and Part B.

Make the Right Choice

Even if you don’t intend to enroll in a Medicare Advantage plan, you should at the minimum seek to understand how they work. That will be the starting point to choosing the best Medicare Advantage plan for you.