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Medicare Advantage plans combine Part A and Part B benefits, and often include Part D (prescription drug) benefits as well. Some beneficiaries prefer to have all of their coverage managed under one comprehensive plan.
You must be enrolled in both Medicare Part A and Part B in order to elect an Advantage plan, and you will continue to pay your Part B premiums. Medicare will then pay the Advantage plan administrator a set monthly amount to manage your care, and your Advantage plan will deliver all of your benefits. You also must live within the Advantage plan’s coverage area.
Much of the difference between the two plans involves the way in which you access your benefits.
With Original Medicare, you are subject to deductibles and a 20 percent co-insurance on Part B. You can access care at any doctor’s office or hospital that accepts Medicare (which most do).
Under a Medicare Advantage plan, you access care through a network of providers in your coverage area. You will owe co-pays that vary for different services, depending upon how your plan is structured. Some plans will charge a per-day co-pay for hospital stays, while others charge a flat amount for the entire stay.
Medicare Advantage plans tend to change more each year, with regard to coverage. However, beneficiaries have the opportunity to review their plans each year, and choose one that best suits their anticipated needs for the upcoming coverage year.
Before Medicare Advantage was created, those with Original Medicare who could not afford a Medigap plan sometimes found themselves swamped in medical expenses when a serious illness or other incident occurred.
Advantage plans were created to provide a sort of safety net for catastrophic expenses. The plans include an out-of-pocket spending cap. When beneficiaries reach that limit, the plan kicks in to cover medical expenses for the rest of the year (although Plan D expenses are calculated and managed separately).
Many Advantage plans also include Part D coverage for prescription drugs, so that beneficiaries don’t have to purchase a separate plan.
With so many options out there, choosing a Medicare plan can feel overwhelming to just about everyone. What works for one person might be completely wrong for another, so this is a very personal decision. Fortunately, insurance professionals dedicate themselves to learning all of the ins and outs of the different options available, and can guide you toward the plan(s) best suited for your needs.
First, ask yourself some important questions to begin identifying your priorities:
HMO stands for Health Maintenance Organization. If you enroll in an HMO plan, you’ll have to select an In-Network Primary Care Physician or PCP. This primary doctor is charged with coordinating your care and must be seen first for all healthcare needs except in an emergency. If a specialist is necessary, the primary doctor will refer you to an In-Network specialist.
HMOs often come at the lowest premiums. However, the plans are less flexible with regard to healthcare providers, and out-of-pocket expenses can vary.
PPO stands for Preferred Provider Organization. In these plans, you do not have to select a primary care doctor and can “self-refer” to a specialist if you deem it necessary. PPO’s have both In-Network and Out-of-Network options. Although you have the freedom to go directly to any doctor you’d like, if that doctor is out of the network it will almost always have significantly higher costs associated.
PPOs can offer more flexibility and out-of-network benefits. However, premiums can run quite a bit higher so it pays to have a broker do some “shopping” for you in order to find the best cost for your circumstances.
As you can see, numerous factors will combine to lead you to your decision. The above summaries are a cursory guide, and are only intended to outline your basic options.
Working with a licensed insurance professional to research all of the options available to you, as well as address concerns specific to your situation, is still the best way to locate a Medicare policy that suits your needs and budget.
Steve NakamotoIndependent Health Insurance Agent
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