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What is Medicare Advantage?

What is a Medicare Advantage plan? How is it different from traditional Medicare?

Medicare Advantage plans are private health plans, such as HMOs or PPOs, offered by insurers that have contracts with the Medicare program to benefit their beneficiaries. The plans provide all the benefits covered by Medicare in Parts A and B and provide Part D prescription drug benefits. Some Medicare Advantage plans may also offer benefits not covered by traditional Medicare, such as eyeglasses, dental care, or gym memberships. The plans also have an out-of-pocket limit for services covered by Parts A and B and may have lower cost-sharing than traditional Medicare for Medicare-covered services.

What is Medicare Advantage?

The Medicare Advantage Program (Part C) gives people an alternative way to receive their Medicare benefits. The program comprises many different health plans (typically HMOs and PPOs) that are regulated by Medicare but run by private insurers. Plans generally charge monthly premiums (in addition to the Part B premium), although some in specific locations are available with no tips.

These plans must include Part A and Part B services as Original Medicare, and most have prescription drug coverage (Medicare Part D). Some plans offer additional benefits not included in Original Medicare, such as hearing, vision, dental coverage, and fitness programs.

Unlike the original program, Medicare Advantage plans operate in limited geographic areas. HMOs (health maintenance organizations) generally require you to go to doctors and hospitals within the plan’s regional network, except in an emergency; PPOs (preferred provider organizations) allow you to go out of the regional network, but you must pay higher copays. For this reason, Medicare Advantage plans are not suitable for people who live in more than one state during the year (people who like the sun or snow) or who travel a lot.

Each calendar year, Medicare Advantage plans can vary costs (premiums, deductibles, and copays). To make sure you get the best price, you can compare programs in your area during the open enrollment period (October 15 to December 7) and, if you want, switch to another plan for the following year.

To join a Medicare Advantage plan, you must be enrolled in Medicare Parts A and B. The procedure cannot deny your request, regardless of your medical needs, except under this circumstance: You cannot join a plan if you have kidney failure (a disease of the end-stage kidney requiring dialysis or a kidney transplant), but you can still get care for this condition through the Original Medicare program. Medicare Advantage plans can’t charge you higher premiums, deductibles, or copays because of your current health status or a pre-existing condition.

Please note that Medicare Supplement (Medigap) insurance does not work with Medicare Advantage plans, and therefore you must pay out-of-pocket costs (copays, deductibles). 

Medicare Eligibility Criteria

In general, people are fit if

  • Are you 65 years or older
  • Are you undergoing dialysis or have had a kidney transplant
  • Are under age 65 and have specific disabilities
  • Have amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)

People under the age of 65 and eligible to be covered by Social Security Disability Insurance for at least 24 months may be eligible for Medicare.

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