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Congress designed this program to give Medicare beneficiaries a lower-premium option than Medigap. They also have very little Medicare underwriting. This means they are a coverage option for people who missed their open enrollment window for Medigap and now cannot qualify for Medigap due to health conditions.

Medicare Advantage plans are NOT similar to Medigap plans – they are different. Members get their benefits from a private insurance company instead of original Medicare. Sometimes you’ll hear them referred to as Medicare replacement plans.

How Medicare Advantage Works

A Medicare Advantage plan is a private Medicare insurance plan that you may join as an alternative to Medicare. When you do, Medicare pays the plan a fee every month to administer your Part A and B benefits. You must continue to stay enrolled in both Medicare Part A and B while enrolled in your Medicare Advantage plan. Medicare pays the Medicare Advantage company on your behalf to take on your medical risk. This is how Medicare Advantage plans are funded.

You will present your Advantage plan ID card at the time of treatment. Your providers will bill the plan instead of Original Medicare.This is why some providers consider them Medicare replacement plans, but it’s important to remember that you can always return to Original Medicare during a future annual election period.

Each Advantage plan has its own summary of benefits. This summary will tell you what your copays will be for various healthcare services. Your plan will offer all the same services as Original Medicare, such as doctor visits, surgeries, labwork and so on. You might pay $10 to see a primary care doctor. Specialists will often be more – a $50 specialist copay is quite common. Some of the higher copays may come in for diagnostic imaging, hospital stay, and surgeries.

You can usually expect to spend several hundred on copays for these items. However, this varies greatly between states, so review plans in your area to get the specifics.

One neat thing about Medicare Advantage plans is that some of them offer benefits for routine dental, vision or hearing. Some plans include gym memberships.

Medicare Advantage Networks

In exchange for lower premiums that Advantage plans offer, you agree to play by certain rules. Most Medicare Advantage plans have HMO or PPO networks.

Medicare HMO networks generally require to treat only with network providers, except in emergencies or urgent care situation.

Medicare HMO plans are the most popular type of network.

Medicare PPO networks allow you to see doctors outside the network but you may have higher out-of-pocket spending to do so.

It’s a personal choice. If you are deciding between Medicare Advantage and Medigap, you’ll want to consider some of the rules before you enroll.

Basic Medicare Advantage Rules

  • You must be enrolled in both Medicare Part A & B and you MUST continue to pay for your Part B premium.
  • You must live in the plan service area.
  • Medicare Advantage plans have one health question:  Have you been diagnosed with End-Stage Renal Disease (kidney failure)?
  • Use network doctors and hospitals for the lowest out of pocket costs. Plans may have HMO or PPO networks. Most Medicare HMO plans do not cover anything out of network except emergencies and urgent care situations. In PPO networks, seeing a provider outside the network may result in higher spending.
  • Get prior authorization for certain procedures, especially in Medicare Advantage HMO plans.

Put your red, white and blue Medicare card in a safe place. Do not give it to any of your healthcare providers. If they bill Medicare, those bills will be rejected. You must direct your providers to bill your Medicare Advantage plan. People who enroll in Advantage plans for Medicare are agreeing, for the rest of the calendar year, to be covered by the plan instead of Original Medicare.

Medicare Advantage Enrollment Periods

Medicare Advantage plans have lock-in periods. You can enroll in one during Initial Enrollment Period when you first turn 65. After that, you may enroll or dis-enroll only during certain times of year. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year. You may only dis-enroll from an Advantage plan during specific times of the year.

The Annual Election Period in the fall is the most common time to change your Medicare Advantage plan. This period runs from October 15th – December 7th each fall. Changes made to your enrollment will take effect January 1.

If you decide to leave a Medicare Advantage plan and return back to Original Medicare, you must notify your Medicare Advantage plan carrier. Otherwise Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare. This is a common billing nightmare that we see among people who enrolled on their own without the help of an agent.

It is in your interest to enroll in Medicare Advantage through an insurance agent who can fully explain how the plan works. Enrolling without an agent means you are on your own if problems occur on the back end of your policy.

Medicare Advantage Disenrollment Period

Some people don’t realize this and join Medicare Advantage plans without the help of an agent. Therefore they don’t know about all of these rules. Sometimes they find themselves enrolled into a plan that their doctor doesn’t accept or that doesn’t include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan.

For this reason, Congress designed the Medicare Advantage Disenrollment Period (MADP). The MADP runs from January 1st – February 14th each year. During this time, you can disenroll from any Medicare Advantage plan and return to Original Medicare.

Unfortunately, this does not guarantee that you can return to the Medigap plan you had before. Unless this was your first time ever in a Medicare Advantage plan, then you will usually have to answer health questions and go through medical underwriting to get re-approved for Medigap. Consider this before dropping any Medigap plan to go to Medicare Advantage.

Medicare vs Medicare Advantage

The intent of Congress in creating these plans was to give you options in accessing your Medicare benefits. Some reasons why people might choose an Advantage plan are:

  • Many plans have low monthly premiums (although you must continue to pay your Medicare Part B premium)
  • You pay for medical services as you use them in the form of copays and coinsurance
  • Unlike Original Medicare, Medicare advantage plans have an out of pocket maximum cap to protect you against catastrophic spending
  • The convenience of having your medical and Part D drug benefits rolled into one plan
  • Some plans may include benefits for things like dental, vision, hearing, health club memberships and a 24 hour nurseline. Limitations, copayments, and restrictions may apply.

Remember, it’s a personal choice – there is no right and wrong. Consider Original Medicare vs Medicare Advantage based on your own knowledge of your medical usage.

Medigap vs Medicare Advantage

Without question, Original Medicare with a Medigap plan gives you very comprehensive coverage. The primary differences are that with Medigap plans, you can see any doctor that accepts Medicare. You don’t have to ask your doctors if they take your specific Medigap insurance company. The network is Medicare, which has over 800,000 providers. The network is nationwide, not local.

Medigap plans also have fuller coverage on the back end. Medicare pays 80% and your Medigap plan 20%, leaving you with little out of pocket. You won’t have the repetitive copays that you will on a Part C plan.

Medigap plans also don’t change their benefits from year to year. This means they don’t require as much homework from you. You won’t have to annually review the upcoming benefit changes like you will on an Advantage plan.

However, Medigap plans do not include Part D coverage, so you will need to buy a separate Part D policy. They also do not offer any routine dental, vision or hearing while some Medicare Advantage plans may at least have a little bit of this.

You can learn more about Medigap vs Medicare Advantage here.

Again, there is no right or wrong. The two types of coverage just work differently.  Go with the option that feels right for you.

Other Considerations about Medicare Advantage

Be sure to carefully consider these things before joining a plan:

  • Not all hospitals and doctors accept Advantage plans. Ask your agent to help you verify whether your medical providers accept the plan you are interested in.
  • Advantage plan benefits may change every year. In September, you will receive a packet from your Part C insurance company telling you what is changing. The plan’s benefits, formulary, pharmacy network, provider network, premium and/or co-payments and co-insurance may change on January 1 of each year. Will you be diligent enough to review your annual packet and communicate with your agent if you have concerns about the changes?
  • Your enrollment is generally for the entire year. You may only dis-enroll from an Advantage plan during certain times of the year. If you decide in April that you don’t like the plan, you will have to wait until the following annual election period begins in October in order to change your plan unless you qualify for a special election period.

If you enroll in one right out of the gate at age 65, you need to be sure you want this coverage long-term. Your open enrollment window to get a Medigap plan with no health questions ends at 6 months past your Part B effective date. You might not be able to get a Medigap plan later if you have health conditions because applying for Medigap later will require you answer medical questions. You can be turned down for Medigap at that point if you are not healthy enough to qualify.

Special circumstances (Special Enrollment Periods)

You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP. You may qualify for a Special Enrollment Period if you:

  • Retire and lose your employer coverage
  • Move out of the plan’s service area
  • Receive assistance from the state
  • Receive benefits from the VA or have TRICARE

Have been diagnosed with certain chronic health conditions


People often ask us our opinion on which plan is the best Medicare Advantage plan. This varies based on a number of personal factors. What’s right for your friend or neighbor may not be right for you. Don’t risk making a mistake on something as critical as your health insurance. Get help from an experienced agent who can explain your options in detail.

Contact Senior Insurance Solutions for help today at (414) 241-6143! We work with numerous plans, and we can guide you through your options.

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