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Medicare Advantage Plans – What Exactly Is The Advantage?

Whether you’re new to Medicare or you’ve had Original Medicare for a while now, you’ve no doubt heard about Medicare Advantage. This private alternative to traditional Medicare is popular among Medicare enrollees. Over the last decade, enrollment has more than doubled, jumping from about 10.7 million people in 2010 to 23.4 million people in 2020.

And as of 2021, about 42% of people with Medicare now get their benefits through Medicare Advantage instead of Original.

But what’s the advantage to Medicare Advantage, really? Is it worth the hype?

We can’t tell you which option to choose for your benefits. Health insurance isn’t a one-size-fits-all product, even when it comes to Medicare. But we can highlight some of the pros of Medicare Advantage — and some things to keep in mind — while you look for the best coverage for your needs.

What Medicare Advantage Covers

Medicare Advantage plans are sold by individual companies, but they’re regulated by the federal government. By law, Advantage plans have to cover at least the same benefits as Original Medicare, which is Parts A and B together. So at minimum, your private Medicare plan is going to cover what Part A and Part B cover (hospital coverage and medical coverage, respectively).

But because these are individual plans sold on the private market, there’s leeway in what else they can offer beyond Original Medicare. They also have flexibility in how they cover certain benefits. This means, for example, that you might have a higher coinsurance rate for hospital stays up front but more covered time at the hospital than Part A allows.

Advantage plans can also cover things that Original doesn’t. This can include, among other things:

  • Prescription drugs
  • Dental and vision benefits
  • Hearing aids and the exams to fit them
  • Routine foot care
  • Chiropractic and acupuncture beyond Original Medicare limits
  • Telehealth visits
  • Post-hospital meal delivery
  • Gym memberships

Medicare Advantage plans can also cover so-called innovative benefits for people who are chronically ill. This might include things like pest control services, carpet cleaning, bathroom assistive devices or other things that aren’t medically necessary but could improve quality of life.

Coverage varies by plan when it comes to Medicare Advantage. Again, you’ll always get the coverage you would under Original Medicare. That’s a legal requirement. But beyond that, individual Advantage plans can create more flexible plans with broader benefits.

Eligibility & Enrollment in Medicare Advantage

You’re eligible for Medicare Advantage once you’re enrolled in Original Medicare (Parts A and B together). You have to have both parts to enroll in Medicare Advantage. Once you do, you can sign up for Advantage for the first time during specific enrollment windows:

  • Initial enrollment period. When you’re first eligible for Medicare, you have 7 months to enroll yourself (if you don’t qualify for automatic enrollment). This is called your Initial Enrollment Period (IEP) and it lasts for 7 months: 3 months before the month you turn 65, the month you turn 65 and the 3 months after. So, for example, if your birthday is August 8th, your IEP runs from May 1st through November 30th the year you turn 65. Once you enroll in both Part A and Part B, you can then sign up for Medicare Advantage.
  • Open Enrollment Period. Each fall, Medicare members with existing plans can make changes to their coverage for the coming year. This is called the Open Enrollment Period (or annual election period) and it’s open to anyone who already has Medicare. If you have Original Medicare and want to enroll in Medicare Advantage, this is the time to do it. The OEP runs from October 15th through December 7th each year. Changes take effect on January 1st.
  • After general enrollment. If you enroll in Part A when you’re first eligible but don’t get Part B, and then decide to enroll in Part B during the Medicare General Enrollment Period (January 1st through March 31st each year), then you can join a Medicare Advantage plan after you enroll in Part B. This is a special enrollment window for a specific situation, and it runs from April 1st through June 30th. Coverage starts on July 1st.

There’s also a Medicare Advantage Open Enrollment Period that runs at the same time as the general enrollment period (January 1st through March 31st). But this is for people who already have a Medicare Advantage plan. You can use this window to make a one-time change to your plan, which will take effect on the first of the month following the month you make the change.

As of 2021, people with end-stage renal disease (ESRD) can now enroll in Medicare Advantage plans when they become eligible for Medicare. This wasn’t the case before. To learn more about ESRD and Medicare, visit Medicare.gov.

The Advantages to Medicare Advantage

There are several advantages to enrolling in Medicare Advantage over staying with Original Medicare. It may not be right for everyone, but Advantage offers some benefits that are hard to ignore, especially as you get older and may need more costly care. The advantages to Medicare Advantage include coverage options, cost and convenience.

Coverage options

Medicare Advantage plans vary in what they cover. Most (but not all) cover prescription drugs, some level of dental and/or vision coverage and added perks, like a gym membership or access to fitness programs. Others may offer even broader coverage. If you need these benefits, especially things that Original doesn’t cover, such as prescriptions, Medicare Advantage can be an affordable way to package them together under one plan.

And because benefits vary from one plan to the next, you’re likely to find something that works for you. Unlike with Original Medicare, you have choices in the kinds of benefits you get with an Advantage plan.

Cost

Premiums tend to be low for Medicare Advantage. Regardless of how you get your Medicare benefits, you’ll always pay your Part B premium (and Part A, if you have a premium for it). But some Medicare Advantage plans charge an additional premium on top of this. Others don’t.

On average, the premium for Medicare Advantage in 2022 is about $23 a month. But most people with Medicare (99.6%) have access to at least one Advantage plan without a monthly premium.

Plus, cost sharing might be lower for some services under Advantage vs. with Original Medicare. Instead of 20% of the cost of all services under Part B, with no out-of-pocket maximum in place, you might have different copays to see a doctor.

And Medicare Advantage plans have to cap out-of-pocket expenses for the year, something that Original Medicare doesn’t do. So not only could you find broader benefits with a private plan, but you may also save money out of pocket for the care itself.

Convenience

Medicare Advantage plans are convenient. Instead of juggling Original Medicare and a standalone Part D plan — not to mention a Medicare supplement plan to offset your out-of-pocket costs, if you need one — you could enroll in one health plan that takes care of your medical and drug benefits in one tidy package.

This is similar to how health insurance works for the under-65 crowd and closer to what you might have had before you qualified for Medicare.

Of course, not every Medicare Advantage plan covers prescription drugs. But if you need this coverage and want the added benefits that can come with private plans, Advantage is a convenient way to get these benefits.

Things to Keep in Mind

Medicare Advantage can be a good option for most Medicare enrollees. But there are a couple of things to keep in mind before you trade Original Medicare for the private alternative:

Network restrictions may affect who you see and when.

There are different types of Medicare Advantage plans, with the two main types being health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

HMOs are more common. This type of policy has a strict network of providers and only covers care that you get inside that network, unless it’s an emergency. With an HMO, you’ll have to have a primary care doctor, and this doctor coordinates your care with other providers. That means you’ll need referrals to see specialists. The tradeoff for these kinds of restrictions is lower monthly costs. HMOs tend to be less expensive than PPOs.

PPOs, on the other hand, will typically cover in- and out-of-network care, though you’ll pay less out of pocket if you stay within the plan’s network. PPOs might cost more, but they can be more flexible in terms of who you can see and when. You don’t usually need a referral to see a specialist with a PPO, and you aren’t required to have a primary care doctor.

In any case, though, Medicare Advantage plans do have networks. Original Medicare does not. You can see any provider who accepts Original Medicare, and you don’t need a referral to see specialists. If you need certain doctors or specialist care, make sure you find a Medicare Advantage plan with a network that covers who you want and need to see.

Network restrictions can be a sticking point if you live in an area without access to a lot of specialists or you want to stay with a doctor who’s not in anyone’s network.

You may not be able to get Medigap again.

This is an important point that doesn’t get mentioned much and can be confusing to people who originally had a Medicare supplement plan.

Let’s say you start out with Original Medicare and a Medigap (Medicare supplement) policy — which helps offset out-of-pocket costs under Parts A and B — and later decide to switch from Original to Medicare Advantage. You can’t have Medigap and Medicare Advantage at the same time, so you drop Medigap as well. If you then decide to go back to Original Medicare and want a new Medigap policy to go with it, you may not be able to get one.

The reason is because there’s only one guaranteed time when you can enroll in Medicare supplement plans without facing medical underwriting. It’s called Medigap Open Enrollment, and it starts when you enroll in Part B for the first time and you’re 65 years old. Being 65 and enrolling in Part B triggers an automatic, unchangeable initial enrollment window for Medigap policies. During this 6-month window, you can buy any Medigap plan available to you.

Once that window closes, Medigap may no longer be available to you. That’s because companies selling Medicare supplement plans can use medical underwriting, which involves taking a look at your health history, to set rates or deny your application altogether.

So back to our example. If you’ve been in a Medicare Advantage plan for a while and decide to drop it for Original Medicare, you may not be able to get a Medigap policy at that point. Some states have different rules on this, but generally speaking, Medigap plans can use medical underwriting to deny coverage or charge more for their policies once you’re outside the initial signup window.

Now, there may be exceptions. Medicare is full of exceptions and special stipulations for different scenarios. But before you enroll in Medicare Advantage, check with Medicare (and/or your current Medigap plan) to see what the consequences might be of dropping Medigap in your situation.