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You may have heard of Medicare Advantage Plans, but do you know how to shop for one (or how they fit into the Medicare universe)?
Medicare Advantage Plans are an “all-in-one” alternative to Original Medicare — meaning they replace Medicare Part A (hospital coverage), Medicare Part B (medical insurance) and often Medicare Part D (drug coverage). Also known as Medicare Part C or MA Plans, they’re offered by private insurers that have been approved by Medicare. Most plans offer additional benefits that aren’t covered under Original Medicare, which may include dental, hearing and vision coverage. You’ll probably be required to stick with doctors in the plan’s network, but out-of-pocket costs may be lower.
Where should you start?
The best place to start shopping for Medicare Advantage Plans (or a Part D or Medigap policy) is Medicare’s Plan Finder tool. After answering a few questions about your location and any financial help you might be receiving — from Medicaid, for instance — the tool will show you all available plans that meet your criteria.
If you want to see drug costs when you compare plans, you can enter the name, dosage, quantity and frequency for each drug you take regularly — and even the pharmacy where you get prescriptions filled. The final list will then be populated with your expected drug costs in each plan. Filter plans by available benefits, plan type, ratings, insurance carrier and drug coverage options. Select up to three plans for side-by-side comparison.
If you’re a little overwhelmed by online tools, you can find live human help from State Health Insurance Assistance Programs (called the SHIP network). “It’s basically the equivalent of a hotline or in-person counseling,” says Riaz Ali, CEO and founder of health care solutions company Saeidan and creator of plan comparison site Ask Claire. “They will not recommend a plan, but they can help you through the process.” Each state has its own SHIP program — find your local program at shiptacenter.org.
What Medicare Advantage Plans are available?
There are five types of Medicare Advantage Plans:
Health maintenance organization, or HMO, plans: Require you to see an in-network provider unless it’s an emergency situation, and most require a referral to see a specialist.
Preferred provider organization, or PPO, plans: Allow you to see both in-network and out-of-network health care providers, although it’s usually more expensive to go out of network.
Private fee-for-service, or PFFS, plans: Allow you to see any Medicare-approved health care provider as long as they accept the plan’s payment terms and agree to see you. You may also have access to a network of providers. You can see doctors that don’t accept the plan’s payment terms, but you might pay more.
Special needs plans, or SNPs: Provide benefits to people with certain diseases, such as cancer, or health care needs, such as living in a nursing home. These plans also provide benefits to people with a limited income.
Medical savings account, or MSA, plans: Combine a high-deductible insurance plan with a medical savings account that can be used for health care costs.
What should you consider?
While you might not have an abundance of Medicare Advantage options if you live in a rural area, urban dwellers could have two dozen or more choices available. Narrow the field with these strategies:
Find the star rating. Medicare collects data on Medicare Advantage Plans from member surveys, the plans themselves and health care providers, then assigns a star rating based on its findings. “It’s based on performance on a range of different things to do with quality, including things like, ‘How responsive is the plan to any complaints or questions?’” says Anne Tumlinson, CEO of health care research and consulting firm ATI Advisory. The star rating goes from 1 to 5 stars, with 5 stars being excellent.
Check the numbers. The two primary cost considerations are a plan’s premium and the maximum out-of-pocket cost, which is the most you’ll pay in a year for covered health care. “That’s usually something people care a lot about,” Ali says.
Consider your meds. The Medicare Plan Finder and some private comparison sites allow you to enter your regular prescriptions to help determine plan coverage and cost.
Cross-reference your health care providers. If you’ve got a regular network of caregivers and medical facilities, you’ll probably want a plan that includes them.
Think about your preferences. If you see specialists frequently and you don’t want to request a referral for every office visit, a PPO plan will be a better option than an HMO. If you’re a light health care user and see mostly your primary care physician, an HMO might be more affordable.
Visit the plan’s website. Before you pull the trigger on a plan, go to the provider’s website and make sure you understand all the benefits — and limitations. “What we’re seeing is that plans are offering these new and different benefits, like in-home palliative care,” Tumlinson says. Those are exciting and, if you have a need, they’re something to consider. But these new benefits are often quite limited, so check the plan directly.
Call the carriers. Ali goes one step further, advising consumers to call a carrier directly if you’re thinking of enrolling or switching to their plan. “We believe the truest source comes directly from the carrier themselves,” Ali says. “If you’re interested in switching, connect with those carriers. Do one additional step of due diligence.”
When can you sign up?
You can enroll in a Medicare Advantage Plan (or switch from one to another) during the following windows:
During your initial enrollment period.
Each year during open enrollment from Oct. 15 to Dec. 7.
From Jan. 1 to March 31, during Medicare Advantage open enrollment, you can switch from one MA Plan to another (but you can’t enroll in an MA plan if you aren’t already in one).
If you are switching plans, you’ll be automatically unenrolled from your old plan once your new one starts.
If you have any questions about the process, you can reach the folks at Medicare at 1-800-MEDICARE (1-800-633-4227), or you can find information at Medicare.gov.
Frequently asked questions