What is Medicare Advantage?

Breakdown of Medicare Advantage for Seniors

by Amy De Vore+ on Jun 23, 2014 | 4 Comments

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Medicare Advantage (MA) is offered by a private company that is contracted through Medicare to provide seniors with Part A and Part B benefits. These plans are usually HMOs or PPOs, but can also be a Private Fee-for-Service Plan, Special Needs Plan, or Medicare Medical Savings Account Plan.

How do Medicare Advantage Plans Work?

Medicare Advantage plans replace Original Medicare in the following ways:

  • Medicare Advantage must follow Medicare’s rules
  • Medicare Advantage plans are local, HMO/PPO type networks
  • Medicare pays toward your care each month to your chosen provider of Medicare Advantage plans
  • Medicare Advantage plans can charge different out-of-pocket costs for services depending on provider and plan
  • Although MA must follow Medicare’s rules, these plans may set up how you receive services**
  • Most MA plans offer prescription drug coverage
  • You cannot have Medigap and Medicare Advantage at the same time

**Each Medicare Advantage plan may set up its own way of how your receive services, such as if you need a referral for a specialist and if you have to stay in network. You will need to check with your provider to see how your plan works for you.

Medicare Advantage Pros and Cons

Medicare Advantage plans, like most things, have pros and cons. Let’s go over the positives first:

Medicare Advantage Pros

  • Medicare Advantage allows for seniors to pay one monthly premium for all services
  • MA plans can have the least expensive premiums (sometimes even a $0 premium)
  • Many MA offer extras like dental, vision, gym memberships, and Rx coverage
  • Medicare Advantage has open enrollment every year where you can change your plan
  • MA plans have an out-of-pocket max, usually $6,700 per year
  • Some Medicare Advantage Plans cover emergency services worldwide

Medicare Advantage Cons

  • Local HMO/PPO type network
  • To see a doctor outside of your network may cost you 100% of charges
  • Co-payments may be due each time you seek medical services
  • Often each MA plan will have gaps in coverage
  • Each plan is slightly different which makes them hard to compare
  • Many plans have deductibles

Why Choose Medicare Advantage?

Medicare Advantage offers a lot of benefits at a low-cost. These plans are inexpensive, basic plans, that can limit your out of pocket costs, as long as you read the fine print, are okay with copays that can add up and a limited network, this might be the right fit. If you have further questions call the number above or contact Senior65.



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Reader Comments and Questions

By Taylor on June 14, 2018

I just wanted to thank you for helping me learn more about medicare advantage. I didn't know that this plan can offer other advantages, like dental or gym memberships. I wouldn't mind knowing if these extra things depend on where you're located or if there's a separate amount set aside specifically for this.

Give us a call and we would be glad to answer your MA questions!
-Amy from Senior65.com

By jr on April 27, 2017

is is my understanding that some states/zip codes provide a class 5 plan... that would mean that some zip codes allow for open enrollment while others don't assuming you meet the loop hole criteria which is that you have already had some kind of prescription plan and want to convert the current to other coverage... i hope my understanding is correct. if it is where is the fairness and who chooses those zip codes that can qualify or offer year round enrollment why us others have to wait until open enrollment in october... i guess if you get sick during the closed months of any plan, it's your problems to pay for any drugs you need during the lapse time.. is my statement right and is this fair to everyone?

You are correct! I'm just going to clarify for those that are not so in the know that are reading your comments. If you are enrolled in a Medicare Advantage you can only switch your plan during Open Enrollment (Oct 15-Dec 7), unless you have a Special Enrollment Period, or if you want to leave a non-5 star rated MA plan for a 5 star rated plan (this is what JR is talking about in the above comment). Unfortunately, most areas do not have 5 star plans.

To answer question, is this fair? Here's our best response: It encourages MA providers to strive to be a 5-star plan, so that they can be the one you would switch to. Therefore, plans are striving to be the best, and hopefully all will be 5 star plans soon. If you need help finding a Medicare Advantage plan, give one of our Senior65 licensed independent insurance agents at 800-930-7956.
-Amy from https://www.senior65.com/

By Leviticus Bennett on March 24, 2017

That's nice that medicare advantage plans offer extras for least expensive premiums. I'm going to help my grandparents choose a medicare plan, so I'm trying to do my research. My grandparents would love a plan that gets them a gym membership, so I'll keep in mind this type of plan.

By marianne on December 22, 2016

One more question re Medicare Advantage plans (HMO) Does the maximum out of pocket include out of network procedures/doctors? Thank you!

Medicare Advantage HMO plans out of pocket maximums only count toward in-network providers -as HMOs do not cover any out of network services. If you want a plan that covers both you will want to consider a PPO. If you need help finding a PPO plan in your area call one of our Senior65 licensed independent insurance agents at 800-930-7956.
-Chris from https://www.senior65.com/

PLEASE NOTE: We cannot comment on specific Medicare claims. Contact Medicare directly if you are trying to see if your issue is covered.

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