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Medicare Advantage Plans. what they are and the pros and cons of them

By March 17, 2016No Comments

Medicare Advantage Plans are an alternative health insurance plan to Original Medicare often referred to as MA Plans.

They are distributed by Medicare approved Private Insurance Companies and are regulated by the the Centers of Medicare Services (CMS).

What they offer

Medicare Advantage Plans are required to provide all of Part A (Hospital Insurance) and Part B (Medical Insurance) that is within Original Medicare. These plans may also offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs, though, they are not required to cover hospice care.

Most also include Medicare prescription drug coverage (Part D), but the extra coverage is determined by the provider and the depth of the plan itself.

How they work

Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans in the form of subsidies. This is to ensure that there is adequate competition and coverage for retirees.

The companies that receive these subsidies must follow rules set by Medicare. Each Medicare Advantage Plan can charge different out-of-pocket costs and may have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care).

Please note that these rules can change on an annual basis.

Premiums, Deductible and Co Pays:

All plan members pay some premium regardless of age, gender, or health. Cost sharing (co pays) must be paid for most medical services.

Many plans have an out of pocket annual maximum which is set by the companies themselves. The difference in premiums is created by the different types of coverage needed by the beneficiary.

*The premium for MA Plans may be higher than the monthly premium for Medicare Part B.

Types of Plans
  • HMOs – maintains a provider network and referrals may be necessary
  • PPOs – also has a provider network, but allows beneficiaries to obtain care outside the network if they pay higher amounts.
  • PFFS – no network which may lead to issues finding providers that will accept it
  • SNPs – membership is limited to certain groups of people, such as those in certain institutions (like a nursing home), those eligible for both Medicare and Medicaid, or those with certain chronic or disabling conditions.
  • HMOPOS -an HMO plan that may let you get some services out of network for a higher cost.
  • MSA – Medical Savings Accounts
Prescription Drug Coverage:

If choosing a PPO or an HMO a beneficiary must, also, enroll in a provided Rx plan of that Provider.
If choosing a PFFS plan a beneficiary can choose either the plan’s Rx coverage, or a stand-alone PDP.


There is no standard for Medicare Advantage Plans. Any Private Insurance Company can build what they believe the market wants, but, they must meet the regulations set CMS.

*It is illegal for someone to sell a beneficiary a MediGap Policy if there is already an Advantage Plan in effect.

The Pros to MA Plans:
  • Freedom to choose any doctor or hospital within the network of your plan provider.
  • Affordable monthly plan premium for most plans.
  • Referral-free visits to any provider nationwide.
  • Prescription drug coverage equal to or better than the standard requirement for a Medicare Part D plan – Drug coverage is not available for all plans.
  • Emergency coverage anywhere in the world.
  • Affordable co-payments for doctor visits and annual routine physicals.
  • Coverage for annual screenings at no charge.
  • Out-of-pockets costs that may be lower when choosing a provider from list of in-network providers.
  • All the benefits of Original Medicare and more, including:
    • The possibility for coverage of Dental, Hearing and Podiatry. This coverage can be an add on to the basic plan and may higher costs.
The Cons to an Advantage Plan

From a report created by the Medicare Rights Center that is  based on thousands of beneficiary calls to the Medicare Rights Centerit lists nine common problems with Medicare Advantage plans that include the following:

  • Care can cost more than it would under original Medicare.
  • Private plans are not stable. Because of this, plans may suddenly cease coverage.
  • Members may experience difficulty getting emergency or urgent care.
  • Because plans only cover certain doctors, the continuity of care is often broken when the plan drops a provider.
  • Members have to follow plan rules in order for care to be covered.
  • There may be restrictions in choices of doctors, hospitals, and other providers.
  • It can be difficult to get care away from home.
  • The extra benefits offered often turn out to be less than promised.

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