As you begin your Medicare research, learning about Medicare Advantage plans and how they work is essential to understand your plan options fully. Medicare coverage is not exactly like the coverage you are used to, whether that was from an employer or the Affordable Care Act. There are two main plan types, Medicare Supplement and Medicare Advantage, but dozens of options exist within those plan types. If you’re looking to explore the options in your area, visit Boomer Benefits – Medicare Advantage to learn more.

The tricky part is that the plans available will depend on your zip code. Therefore, your options can vary significantly compared to someone else. Since there is variation among Medicare Advantage plans, you’ll want to take the time to grasp how these plans work.

What is Medicare Advantage?

Medicare Advantage is an alternative way to receive your Medicare benefits from a private insurance company rather than the federal government. Also commonly known as Medicare Part C. When you enroll in a Medicare Advantage plan, you receive your Part A, Part B, and sometimes, Part D benefits all in one. These plans are usually HMO or PPO plans, similar to employer-offered plans.

To qualify for an Advantage plan, you must be enrolled in Medicare Parts A and B and continue to stay enrolled even when you apply for an Advantage plan. A common mistake many beneficiaries make is failing to pay the Part B premium when enrolled in an Advantage plan. Don’t make this mistake! This is very important because if you miss your Part B premium payment and lose Part B, you will also lose your Medicare Advantage plan.

Medicare pays the Advantage plan insurance carrier a certain amount each month to provide you with your Medicare benefits and take on your medical risks. The plan manages your care as soon as your Advantage plan is effective. This means Medicare is no longer approving or denying your services; the Advantage plan is. So, if you experience denied claims or need prior authorization, everything is handled by the insurance carrier.

What do I pay for a Medicare Advantage plan?

If this kind of plan interests you, you’re likely wondering how much it costs to have an Advantage plan. Well, most Advantage plan premiums are extremely low or even $0 monthly. You read that right. You can likely find an Advantage plan that won’t cost you anything monthly just to be enrolled. However, although you might not pay anything monthly, you will pay as you go for your services.

What are my out-of-pocket costs with my Part C plan?

Your cost-sharing will look different with each Advantage plan. All Advantage plans must offer the same benefits you would receive from Part A and Part B, but the plan will set your cost-sharing, in the form of a copay or coinsurance, for each service. For example, a visit to a specialist may have a $40 copay with one plan but a $50 copay with another. Another example is that a hospital stay may have a $300 daily copay with one plan or a $450 copay with another.

Your cost-sharing will differ with each plan, so reviewing these details before enrolling is critical so you know exactly what to expect.

One feature you’ll want to pay attention to is the maximum out-of-pocket limit. All Advantage plans have a maximum limit that caps your expenses. In 2023, that limit can be as high as $8,300. If your out-of-pocket costs reach that amount during the year, the plan will cover 100% of your expenses for the remainder of the year.

Provider networks

One thing that sets Advantage plans apart from Medicare Supplement plans is the provider networks. Advantage plans have a specific service area that they cover. HMO plans provide coverage for in-network services, meaning you go to an in-network provider for that service. You would only have coverage outside the service area if it were an emergency.

However, PPO plans can provide coverage when you see an out-of-network provider for a service. Some plans can even offer national provider networks, allowing you to travel across the U.S. and see providers participating with your plan. Before enrolling in a plan, you’ll always want to ensure your important providers accept it.

Added benefits

An attractive part of Medicare Advantage plans is the added benefits they can provide. Many plans can offer dental, vision, and hearing coverage which are not services you would get through Original Medicare. Plans can provide transportation to and from appointments, gym memberships, OTC allowance, and Part B premium reimbursement. These benefits vary with each plan and can change from year to year.

It’s your choice

Advantage plans are not mandatory, but they can be a great option for many people looking for help with out-of-pocket costs. Whether you prefer a lower premium or additional benefits, Advantage plans may be what you’re looking for.


Please enter your comment!
Please enter your name here