How Medicare Advantage Works

There are only two options when deciding how to receive your Medicare benefits.  You can opt for a Medicare Supplement plan or enroll in a Medicare Advantage / Part C plan with a private insurance company.  These two plans deliver your Medicare healthcare entirely differently.  Medicare Supplements work in conjunction with Original Medicare Part A & B.  Medicare Advantage is a private insurance alternative to Original Medicare.  You can’t have both plans at the same time,  and it must be understood that a Medicare Advantage plan is not the same as a Medicare Supplement plan.

One of the most important Medicare decisions you will ever face is choosing which option to go with…Original Medicare + Supplement or Medicare Advantage.   During your Initial Open Enrollment window opportunity, you can enroll in a Medicare Supplement plan without being declined for any health-related conditions.   If you initially enroll in a Medicare Advantage plan, and later want to upgrade to a Medicare Supplement plan, you’re subject to “health underwriting” questions and your application may be declined.

    Things To Know About Medicare Advantage Plans

The only health question in 2020 that will disqualify you from enrolling in a Medicare Advantage plan is having End-Stage Renal Disease.  You become eligible for enrollment in a Medicare Advantage plan when you're at least 65 years old, or if you're under 65 if you qualify on the basis of a disability.  You must also be a U.S. citizen who has lived in the U.S. for at least 5 consecutive years.

You can enroll in an Advantage plan during your 'Initial Enrollment Period' or during the Annual Enrollment Period between October 15 - December 7.  Your Initial Enrollment Period (IEP) is 7 months long.  It includes the month you were born and the plus the 3 months before and after your birthday month.

You're able to enroll in a Medicare Advantage plan after you have both Medicare Parts A & B. Once enrolled in an Advantage plan, you must continue paying the Part B premium ($145.60/mo. in 2020). You also must live in the Advantage plan’s service area.  If you move and receive your Medicare benefits through an Advantage plan, you'll be given a Special Enrollment Period (SEP) to enroll in a new plan for the service area you've moved to.

Once you are in enrolled in a Medicare Advantage plan, your plan sponsor (United Healthcare/ Humana / BCBS) is paid your Part B premium plus and additional funds from CMS on your behalf; you no longer get your benefits from original Medicare (the federal CMS agency).  Medicare Advantage becomes your primary insurer and all your health care providers must bill your Advantage plan’s insurance company.

Advantage plans utilize network health providers in your plans service area, which includes doctors, hospitals, clinics, labs, durable medical equipment and therapist to keep cost down.  Advantage HMO plans will not cover out-of-network costs unless it’s for a medical emergency.  PPO plans will provide out-of-network coverage at a substantially higher cost to you.  Before enrolling in an Advantage, make sure any doctors, specialist or hospitals that are important to you are in-network

    Here is an example of how most Advantage Plan Cost Sharing works.

·        Small co-pays ($0 - $20) for Primary Care doctor visits

·        Higher co-pays for seeing a specialist ($35 - $50)

·        Co-pays of $250 - $400 for 4 to 7 days for a hospitalization / $0 beyond first few days

·        Outpatient surgery and medical imaging either a co-pay of $200 - $400 or a co-insurance cost of the procedure

Additional information on How A Medicare Advantage plan works can be found at the  Medicare.gov website.