If you’re considering enrolling in a Medicare Advantage plan, it’s important to evaluate your options based on your situation and needs. Here are some top factors to consider when exploring your options: your geographic location, total plan costs, additional plan benefits, formulary composition and medical provider network. Read our concise guide for tips on comparing Medicare Advantage plans and finding the options best suited for you.
The Types of Medicare Advantage Plans Available in Your Area
Medicare Advantage plans serve as a replacement to Original Medicare (Parts A and B) for those who want benefits beyond the standard coverage, such as hearing, dental, vision, wellness programs and prescription drug coverage. The private insurance companies providing these plans offer coverage for care and medical services obtained in-network from specified doctors, health care providers and facilities. That’s why Medicare Advantage (MA) plans are location-specific, and your options differ depending on where you live.
In general, there are five types of Medicare Advantage plans: Private Fee-for-Service (PFFS) plans, Special Needs plans (SNPs) Medicare Savings Account (MSA) plans, Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans. In the greater Washington, D.C. Metropolitan area, the most common plan types are HMO and PPO plans.
HMO and PPO plans both contract a network of local healthcare providers to offer covered medical services, but differ when it comes to limitations on where you can receive care. HMO plans cover routine care only received in-network, with potential exceptions for emergencies. PPO plans have fewer constraints on care access, with the option to visit any provider that accepts Medicare, but often with higher out-of-pocket costs when going out-of-network.
Prior to evaluating your plan options, obtain a list of all the plans offered in your area, and narrow down your choices using the following steps. While your priorities in these factors might vary, it is important to make sure you closely look at the plans and evaluate them based on costs, benefits, formulary and provider network.
Medicare Advantage Plan Consideration #1: Cost
It is important to look at your overall health care expenses when you are evaluating plan costs. Your costs consist of expenditures for:
- Medicare Part B (medical coverage premium), which are set by Medicare and deducted from your Social Security monthly payment. (This is a required payment if you decide to enroll in a Medicare Advantage plan or a Medicare Supplement.)
- Medicare Part C (MA premium), which are plan-specific.
- Out-of-pocket costs, deductibles, copayments and coinsurance.
- Maximum out-of-pocket limit, which is the total amount you can spend on medical care until your responsibility is met. CMS sets a maximum each year for plans to offer up to, but not more. For 2021, it is $7,550.
As mentioned, costs, when enrolled in a Medicare Advantage plan, can include a monthly premium, deductibles, coinsurance and copayments. By using participating providers and generics that are on the plan’s formulary, you can keep your costs to the lowest level. However, your out-of-pocket costs will be higher, especially if you use non-plan providers, since you will have to pay a higher percentage of costs and potentially all costs. Also, your costs will increase if you use higher cost brand name medications or enroll in a plan where your medications are not on their formulary, leaving you responsible for 100% of your prescription drugs. Medicare Plan finder, as well as independent Medicare insurance agents, can assist in identifying the right plans for your medical needs and budget. By estimating your costs, you can establish a total annual budget for each plan, therefore enabling you to evaluate your financial commitment.
It is important to understand that even though Medicare Advantage plans offer financial protection in the form of an annual out-of-pocket limit, this excludes your prescription drug costs. Regardless of your selected plan, Part D benefits administered under a Plan C operate independent of your medical costs. This is why it’s important to consider your health needs and plans that provide suitable coverage at a reasonable cost. It may be helpful to discuss the various options with a licensed Medicare insurance agent, who has experience working through such calculations with their local clients.
Medicare Advantage Plan Consideration #2: Additional Benefits
Medicare Advantage plans offer the same standard medical benefits as Original Medicare, but can also offer additional benefits at no added premium cost. These benefits can include : dental, vision and hearing coverage, over-the-counter (OTC) benefits, transportation to medical providers, prescription drug coverage, wellness programs, gym memberships, 24-hour nurse line access and more. When evaluating your Medicare Advantage plan options, you should weigh the value of these benefits and how they can assist in improving your health, while helping to reduce your out-of-pocket costs. Evaluating all of these facets will enable you to select the right Medicare Advantage plan for the upcoming year.
Medicare Advantage Plan Consideration #3: Prescription Drug Formulary
Many Medicare beneficiaries require prescription drugs to maintain or restore their good health. But if your plan does not cover needed medications, out-of-pocket costs can be very high. Before selecting a Medicare Advantage plan with drug coverage, you should ensure your prescribed medications are covered, or risk paying full-price for those medications until you’re able to change your Medicare coverage at a later date. Consult each plan’s formulary – a list of covered medications that groups prescription drugs into tiers, each with a designated deductible, copayment and coinsurance cost. These formularies can change from year to year, so you should plan to review your plan’s formulary annually to determine if your medications are still covered.
Medicare Advantage Plan Consideration #4: Provider Network
As mentioned above, Medicare Advantage plan types can differ significantly based on network classification and access to care. HMO, POS and PPO plan types have local (and possibly national) networks of participating providers and facilities at which you’re able to seek covered care. These networks determine what doctors, specialists and hospitals you can access at a reduced cost since they are in the network. Going out-of-network will result in higher out-of-pocket costs (which can range depending on the type of MA plan you choose), which is why you should determine beforehand if your plan covers care from the nearby providers you currently see. It is important to emphasize that if you select an HMO plan, you will only have access to plan providers. Other than an emergency situation, going out-of-network for care will leave you 100% responsible for all costs.
After narrowing down the Medicare Advantage plan options available in your area, you’re now equipped to determine which plan choices are most suitable based on your needs and budget. It will require a comprehensive analysis of the coverage, additional benefits and prescription drug coverage you require in a plan, factored against total costs and network restrictions. Based on these factors, you should be able to determine your top plan choices. For assistance evaluating your Medicare Advantage plan choices, get customized help from a local Medicare insurance agent. Contact us at Medicare Portal to get one-on-one consultations with a certified, experienced member of our team today!