What is a Medicare Advantage Plan?

A Medicare Advantage plan is an alternative to Original Medicare (Part A and Part B) only. Rather than having Medicare benefits provided through a government-run program, people who receive the coverage can obtain it through a Medicare Advantage plan, provided by private insurance companies that have been contracted with Medicare.   

For someone to be eligible to receive Medicare Part C, they must:

• Currently have Part A and Part B Medicare coverage

• Continue to have Part A and Part B Medicare coverage

• Reside in the service area for the Medicare Advantage plan being considered

According to the law, all the Medicare Advantage plans are required to offer, at a minimum, the same amount of coverage as the original Medicare Part A and Part B Plans. However, some plans will cover other benefits, too, like dental, vision, hearing, prescription drugs, or specific health wellness programs.

Unlike the original Medicare plans, if someone wants prescription drug benefits, which is provided by Medicare Part D, they should not enroll in a separate Medicare Prescription Drug Plan. A better option is to get the benefit from one of the Medicare Advantage Prescription Drug plans. Not all Medicare Advantage plans will include coverage for prescription drugs, so it is a good idea to double-check with the particular plan being considered.

Which Medicare Advantage Plans are available to you?

Since Medicare Advantage plans are provided through any Medicare-approved private insurance company, the cost and the benefits may vary from one plan to another. Plans are available according to County and Zip Codes.  A plan that is available to a resident of Los Angeles County may not be available to a resident of Orange County and vice-versa.  This is why a licensed agent will ask you the county and zip code you live in. 

Medicare Advantage Plans - is prescription coverage included?

Well the frank answer is yes or no.  It depends on which type of Advantage plan you choose.  Most Advantage plans offered have prescription coverage included with no additional premium.  You can tell the difference between the plans by looking for the acronyms MAPD or MA. 

• MAPD plan - an Advantage plan that has a Prescription Drug (PDP) benefit.  

• MA plan - an Advantage plan that doesn't have a Prescription Drug Plan (PDP) benefit.  

Each carrier and MAPD plan will have a different formulary, so it's very important to verify that your particular prescription or an alternative that you may use is available on the formulary for the plan(s) you are interested in.

Choosing the Right Medicare Plan for you

Each person’s budget and health needs are unique. This means it is necessary to research each of the Medicare Advantage plan options available.  Plan costs, provider networks, services areas, and benefits adjust year to year, which is why speaking with a Licensed Agent (Broker) that offers multiple plans is a great way to narrow down your choices.

• You may review multiple plans at once from an unbiased source who has experience with the customer service levels and treatment of members for the different plans. These are insights just reading the information doesn't give.

• Licensed Agents get the same pay no matter what plan you choose to go with.  This is important to maintain the integrity of the discovery process.  

• A valuable licensed agent should be current on plan changes that will benefit or harm your particular experience with the plans you are looking at.  For example if a carrier now has a Special Needs Plans for Diabetics that covers certain insulins at no charge and you take those medications, you should know about it.  

• The agent will complete the application with you and should continue to service your Medicare concerns, needs and questions from there on. 

When can I join a Medicare Advantage or Medicare Drug Plan?

Special Election Periods (SEPs), the Annual Enrollment Period (AEP) and Medicare Advantage Open Enrollment Period (MA OEP) exist.  

SEPs give current Advantage plan members the ability to change plans during the year due to very specific circumstances.  A fee examples of these circumstances are:

• Loss of employer coverage (retired) 

• Gained or lost Medicaid (Medi-Cal)

• Gained or lost Low Income Subsidy (LIS) prescription assistance

• Moved into an area where another plan is now available or the current plan is no longer available or 

• Member has been diagnosed with an illness that now qualifies for membership in a Special Needs Plan (SNP) that gives specialized benefits for that illness.

AEP occurs October 1 - December 7 of every year and is the time when current Advantage members have the option to review what the plan benefits are for all the plans for the next year.   Important dates for AEP are: 

• October 1-14 you may review the plans available to you, but can't enroll yet. 

• October 15 - December 7 you may choose to continue on your current plan or enroll into a new plan.

• January 1 - the updated version of your current plan or the new plan you enrolled into starts.

What Is the Plan’s Star Rating?

A star rating is one way to determine the performance of the Medicare Advantage plan. Every plan receives a rating of one to five stars. Five stars is the highest rating that a plan can receive. Medicare evaluates all plans based on the five-star rating system, and these scores are calculated yearly.

Are Any Additional Benefits Included?

It is also important to consider if additional benefits are offered. This would include things like routine hearing, dental, vision, and other health or wellness plans.

Also, find out if a prescription drug is included. Are the existing medications a person takes included with the plan’s formulary or the list of drugs that are covered?

What is the Annual Maximum Out-of-Pocket (MOOP)?

MA & MAPD plans don't have deductibles.  Instead they have an Annual Maximum Out-Of-Pocket (MOOP) threshold.  This is the maximum amount of you money will make in copays for services that fall under Medicare Parts A & B during a calendar year.  Once you reach the MOOP, you still receive the services, you just don't make the copay any more for the remainder of the calendar year.   

For example, most plans have a copay for the Skilled Nursing Facility (SNF) benefit.  Let's say the first 20 days are $0 per day and days 21-100 are $30 per day.  Those 80 days would cost you $2400.  Well if the plan has a MOOP of $699, the maximum you would pay is the $699 for those 80 days and any other Medicare A&B services you receive after that will be with no copay.  If you made copays previous to the SNF stay, those would be calculated into that $699 and the SNF stay would cost you less.  

HMO or PPO?

MAPD plans have grown immensely with the varied choice of networks you have available. There are HMO versions and PPO versions in many Californian counties.  The PPO is a viable alternative to getting a Med Supp plan for some people. 

• HMO - assigned network of physicians, medical facilities and service providers that are contracted with the plan.

• PPO - may have an assigned network, but members are allowed to go outside of that network for services.  Copays may vary from in network to out of network. 

Does the Monthly Premium Provide a Good Value?

Some of the Medicare Advantage plans will have premiums that are $0; however, the individual must continue to pay their Medicare Part B premium, along with deductibles, coinsurance, and copayments, that the plan requires.

In Conclusion

I hope that you learned some valuable information from this article. Choosing a Medicare Advantage plan is a big deal, as you usually won’t be able to change it for up to a year. So you will have whatever coverage you choose for that period. If you find the plan doesn’t cover what you need, you will be stuck paying for it out of pocket.

If you think you know someone who might benefit from this article, please share button it. If you'd like to talk about these things or anything else you might have questions about, please contact us whichever way is most comfortable for you.