Medicare Advantage Enrollment Information
Medicare Advantage Plans: The Alternative to Original Medicare
These are the most important things to know if you are considering a Medicare Advantage plan:
- How Medicare Advantage is like Original Medicare
- How Medicare Advantage and Original Medicare Differ
- What Are the Basic Types of Medicare Advantage Coverage
- When Is the Best Time to Join a Medicare Advantage Plan
- How to Change Your Mind and Switch Plans
Choosing how to receive your Medicare benefits is a big decision. You may know that Original Medicare has recurring copayments and deductibles, but what’s the alternative? Let MediGap Advisors help you determine the right Medicare Advantage plan for your needs.
Reviewed by Whitney Kline
Fact checked by Misty Berryman
MediGap Advisors specializes in Medicare Advantage enrollment, so we can offer you expert assistance. We’re independent from the insurance companies and can offer you an unbiased comparison of the coverage available. You can schedule a confidential consultation, get a quote, or speak with a Personal Benefits Manager with no obligation. We do not charge for our assistance.
Here are some easy-to-understand answers to your questions about Medicare Advantage plans.
How Medicare Advantage Is Like Original Medicare
Medicare pays the insurance company that provides your Medicare Advantage plan a fixed amount every month. That helps keep your Advantage plan premiums low (and sometimes $0), but you will still pay Medicare Part B premiums.
Advantage plans must follow the rules established by Medicare. As an Advantage plan holder, you will retain all of your Medicare protections and rights, such as the right to appeal plan decisions.
Advantage plans must include benefits and services covered under Original Medicare Parts A and B. Advantage plans cannot have higher out-of-pocket costs than Original Medicare for chemotherapy, dialysis or skilled nursing facility care.
Original Medicare will cover hospice care and certain costs for clinical research studies even if you purchase an Advantage plan.
You can sign up for a Medicare Advantage plan regardless of any health problems you may have.
The Key Difference: Medicare Advantage vs. Medicare Supplement
When choosing Medicare coverage, it’s important to understand the fundamental difference between Medicare Advantage (MA) and Medicare Supplement (Medigap) plans:
Medicare Advantage Plans are an alternative to Original Medicare. When you enroll in a Medicare Advantage plan, you’re choosing to receive all your Medicare benefits through a private insurance company instead of through Original Medicare. Think of it as replacing Original Medicare with a comprehensive plan from a private insurer.
Medicare Supplement (Medigap) Planswork alongside Original Medicare. You keep Original Medicare Parts A and B, and the Medigap policy helps pay the out-of-pocket costs that Original Medicare doesn’t cover, such as copayments, coinsurance, and deductibles.
Important: You cannot have both a Medicare Advantage plan and a Medigap plan at the same time. They’re two different approaches to Medicare coverage—you choose one path or the other.”
Basic Types of Medicare Advantage Coverage
Even though Advantage plans establish individual rules, there are basically four categories of Advantage plans available. Those are health maintenance organization (HMO) plans, preferred provider organization (PPO) plans, private fee-for-service (PFFS) plans, and special needs plans (SNP). Let’s see how they’re different.
Can I use any doctor, hospital or other health care provider?
Original Medicare approves providers and providers decide whether to accept Medicare payment rates. Not all will accept new Medicare patients.
With a PFFS Advantage plan, you can see any Medicare-approved provider who accepts the plan’s payment terms. Certain PFFS plans establish a network of providers who contract to treat you. You can also use providers from outside the network, but your out-of-pocket costs may be higher if you do.
PPO Advantage plans also provide more coverage when you use in-network providers, but still offer some coverage if you need an out-of-network provider.
HMO and SNP Advantage plans usually restrict coverage to in-network services with these exceptions: emergency care, out-of-area urgent care, and out-of-area dialysis. Certain HMO plans have a point-of-service option that allows you to use out-of-network services, but that usually comes at a higher cost.
Do I have to choose a primary care doctor?
You usually are required to select a primary care doctor with an HMO or SNP Advantage plan. You’ll also need a referral from that doctor before seeing a specialist. Some services like mammogram screenings do not require a referral. PFFS and PPO Advantage plans don’t require you to choose a primary care doctor or get referrals.
Are prescriptions covered?
SNP Advantage plans must cover prescriptions, and most HMO and PPO plans do, too. PFFS plans may, but if your plan doesn’t, you can add a Part D prescription plan. You may have to pay higher-than-normal Part D premiums if you join after you first become eligible for Medicare.
If you have an Advantage plan that covers prescriptions and you join a Part D plan, you’ll be dropped from the Advantage plan and enrolled in Original Medicare. Part D plans only work with Original Medicare.
Advantage plans and Part D plans are not required to cover every possible prescription, so be sure to confirm that the plan you’re considering covers what you need before you apply.
When to Join a Medicare Advantage Plan
The AEP (annual election period) is when Medicare recipients have the option to either purchase or change a Medicare Advantage or prescription drug plan. AEP enrollment applies specifically to Medicare Advantage plans, prescription drug plans and Medicare Advantage plans with prescription coverage. Policies purchased during the AEP time period will begin providing coverage on January 1 of the following year.
When to join a Medicare Advantage plan:
- Every year during the AEP period, which lasts from October 15 to December 7, you will be able to join or change Advantage plans.
- If you receive disability benefits, you may join an Advantage plan from three months before to three months after the 25th month of disability.
- If you’re turning 65, you also have a seven-month period to join. That’s from three months before to three months after the month in which you turn 65.
- You may also be allowed to join when you qualify for Extra Help or Medicaid, if you move to an institution like a nursing home, or if you move out of your existing plan’s service area.
- You can also switch to an Advantage plan that has a five-star rating once from December 8 through November 30 of the following year.
If you are on a transplant waiting list or think you may need a transplant, check with plan representatives before joining to confirm the plan will cover the doctors, other health care providers, and the hospitalization you’ll need. And be sure you understand plan rules about prior authorization.
Why Choose MediGap Advisors?
Understanding the difference between Medicare Advantage and Medicare Supplement plans is crucial to making the right choice for your situation. At MediGap Advisors, we help you understand both options and determine which path is right for you.
Give us a call at 800-913-3416, tell us your situation, and let us do the research for you. We’ve worked with insurance companies offering both Medicare Supplement and Medicare Advantage plans for years. We want to share that experience so you can make a well-informed choice.
Health care is one of the greatest challenges you’ll face during retirement, and MediGap Advisors can help!
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What Our Clients Say
Leslie at MediGap Advisors was incredible. She walked me through all the Medicare supplement options and found me a plan that saves me $85 a month compared to what I was paying before. Her expertise made what seemed overwhelming completely manageable.
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I thought all Medigap plans were the same price everywhere. Boy, was I wrong! MediGap Advisors showed me how different insurance companies price the exact same coverage differently. I’m now saving over $600 a year with better customer service too.
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Tom helped me switch from Plan F to Plan G and explained how I’d save money in the long run. He was right – I’m saving $40 monthly on premiums and the deductible is so small it doesn’t matter. Wish I’d called them sooner!
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MediGap Advisors saved me from a huge mistake. I was about to buy an overpriced Medigap policy directly from an insurance company. They found me identical coverage for $73 less per month. That’s nearly $900 a year back in my pocket!
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The team at MediGap Advisors made Medicare supplement shopping stress-free. They compared multiple carriers and found me a plan that’s $1,200 cheaper annually than what my neighbor is paying for the same exact benefits. Outstanding service!”
– William Park, Tucson, AZ
Where To Go From Here:
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.