Medicare Advantage Health Plans – Don’t Enroll Until You Know These 5 Facts

Every year some people enroll in a Medicare Advantage Plan without doing prior research. Often they enroll in a plan only because it has a low or $0 monthly premium. Not knowing how a Medicare Advantage health plan works can leave you without adequate coverage or cost you more than you anticipate.

Knowing what an Advantage Plan is and how it works is the first step to choosing a suitable plan. The monthly premium should not be your initial concern when researching plans. Premiums are generally quite low and in many cases plan premiums are $0 per month. It’s more important to find a plan that will provide the benefits you find important and one that includes your providers in its network.

5 Things You Should Know About Medicare Advantage


Understanding the following facts about Medicare Advantage Plans will give you the foundation you need to choose the best plan for your circumstances.

1. You must be eligible to join a plan. Medicare Advantage Plans have fairly liberal eligibility requirements.

  • You must be enrolled in Medicare Parts A and B
  • You must live in the plan’s service area
  • Not have end-stage renal disease

2. A Medicare Advantage health plan is not supplemental coverage. When you join an Advantage plan you are still enrolled in Medicare and will be receiving your benefits in a different way. You will have all Part A and Part B benefits but how you pay for your share of covered services will be different than if you were enrolled in original Medicare.

Rather than the standard Part A and Part B deductibles and coinsurance your Advantage plan will have it’s own deductibles, co-payments and coinsurance amounts. Plans also often include Part D coverage and some extra benefits not normally part of original Medicare.

You Medicare Advantage Plan will not supplement original Medicare but rather becomes your Medicare plan.

3. How you receive benefits is different. When you get your benefits from original Medicare you are able to use any provider or facility that accepts Medicare. When enrolled in an Advantage health plan you are generally subject to a provider network. Types of provider networks include:

  • HMO
  • PPO

Its important that you understand how to use your provider network before you join.

An HMO is the most restrictive and requires that you have referrals from your primary care provider to use other providers. You also must receive all of you services in network with the exception of an emergency visit.

A PPO gives you more freedom than the other network types. You are able to pay a little more and use providers who are not in network. You also do not generally require a referral from your primary provider.

An HMO-POS network functions like an HMO except you are able to receive some serveries at specific out-of-network locations. It’s like a hybrid between an HMO and a PPO.

4. Medicare Advantage Plans have specific enrollment periods. Enrollment periods can be broken down as follows:

  • Your initial enrollment period is when you become eligible for Medicare either due to aging-in or receiving benefits due to a qualifying disability. This enrollment period lasts 7 months and begins 3 months prior to the first day of the month your benefits begin.
  • The Annual Election Period is from October 15th through December 7th. You can drop, switch or enroll in a plan during this time.
  • There are also Special Enrollment Periods that either relate to a change in your circumstances, liking moving out of a service area, or having a limited income, like getting Medicare Part D extra help.

5. There could be changes to the Medicare Advantage program. With both political parties wrangling over Medicare and Medicare funding, there could be changes to the program in the future. Add into that mix special interest groups and what changes may take place are anyone’s guess.

Although this is not something to be alarmed about, you may want to pay closer attention to any elected representatives and what stand they take toward Medicare Advantage.

If you have a firm understanding of these facts, you should be able to enroll in a Medicare Advantage health plan that is suitable for your circumstances.

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