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A Medicare Advantage plan is a private health insurance plan that you may opt to get your benefits from instead of traditional Medicare. Originally called Part C, Advantage plans usually have an HMO or PPO network of doctors.

By joining one of these plans, you direct Medicare to pay the plan a set monthly amount for your care. In return, the plan will deliver all of your Part A & Part B services. You must continue to pay your Medicare Part B premium while enrolled in an Advantage plan.

Medicare Advantage are NOT MediGap plans. They work differently.

Medicare Advantage Coverage

With an Advantage plan, you will pay co-payments when you receive healthcare services. Each plan sets its own cost-sharing. For example, you might pay a copay for a primary care doctor visit, and perhaps a higher copay for a specialist. visit Likewise, some plans will charge you a daily hospital copay, and other plans might charge a flat amount for the whole stay.

Limitations, copayments and restrictions my apply, and each plan's benefits, formulary, pharmacy network provider network, premium and copayments may change on January 1 of each year. Members need to be diligent about reviewing the plan materials sent to them each year in September to see what's changing.

All Medicare Advantage plans must include an out-of-pocket maximum cap on your medical spending. The highest cap allowed by Medicare is $6,700, although some plans may be lower. Think of this as a safety net. If you have heavy health spending that results in you spending $6,700 out of pocket in a calendar year, then the plan kicks in and pays the rest for the remainder of the calendar year (Part D expenses are calculated separately.)

These plans also frequently include small extras that original Medicare doesn't cover. Some common examples would be vision benefits, hearing discounts, and health and wellness programs, such as gym memberships. These benefits also can change from year to year.

Another popular feature of Advantage plans is that they often include a built-in Medicare Part D drug plan, which saves you from having to purchase that separately.

Joining a Medicare Advantage Plan

Part C Advantage plans have different networks, premiums, and cost sharing. Working with an insurance agency that specializes in these plans is a great way to ensure that you consider all the variables before choosing your insurance company.

Types of Medicare Advantage (Part C) Plans

It's important to understand the differences between the types of Medicare Advantage plans to see which works best for you. There are several different types of Medicare Advantage plans:

  • HMO (Health Maintenance Organization plan): Lets you see doctors and other health professionals who participate in its provider network. If your doctor is already in network, it could be a good option because you tend to pay less out-of-pocket with in-network doctors.
  • PPO (Preferred Provider Organization plan): Covers both in- and out-of-network providers, giving you the freedom to choose any doctor that accepts Medicare assignment, which can work if you prefer that kind of flexibility.
  • PFFS (Private Fee-for-Service plan): The plan determines how much it will pay providers and how much you must pay when you get care. The treating doctor has to accept the plan's payment terms and agree to treat you. If the doctor doesn't agree to those terms, then the PFFS plan will not cover services through that doctor.
  • SNP (Special Needs Plans): Are especially for people who have certain special needs. The three different SNP plans cover Medicare beneficiaries living in institutions, those who are dual-eligible for Medicaid and Medicare, and those with chronic conditions such as diabetes, End Stage Renal Disease (ESRD), or HIV/AIDS. This type of plan always includes prescription drug coverage.
  • HMO-POS (Health Maintenance Organization - Point of Service plan): Covers both in- and out-of-network health services, but at different rates. You pay less out-of-pocket when you go to in-network doctors, labs, hospitals, and other health care providers.
  • MSA (Medical Savings Account plan): Includes both a high deductible and a bank account to help you pay that deductible. The amount deposited into the account varies from plan to plan. The money is tax-free as long as you use it on IRS-qualified medical expenses, which include the health plan's deductible.

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