What Is a Medicare Advantage Plan?

Medicare Advantage is probably one of the most advertised parts of Medicare, but also the one that takes the most explaining. They are also called Medicare Part C or MA/MAPD for short. They are one of two ways Medicare beneficiaries can expand the benefits they get from Original Medicare (Parts A and B).

So, what is Medicare Advantage? Today, we’re going to talk about how Part C works, what coverage you can expect to find, and who is eligible to enroll.

How Do Medicare Part C Plans Work?

Medicare Advantage plans are sold by private insurance companies that have permission from the federal government. The plans must meet minimum requirements set by the federal Medicare program, which means they must have at least as much coverage as Original Medicare. The exception to this is that they do not have to include hospice care. (You’ll continue to get those benefits from Part A.)

For each person who enrolls in an MA plan, the government pays that private insurer a fee. The reason the insurance company gets paid is that if you enroll in Part C, that carrier will be responsible for paying your medical expenses that would have otherwise fallen under Parts A and B. The government will no longer be paying those claims – the insurance company will. So, by enrolling in Part C, you are wrapping your benefits from Parts A and B into one plan. However, you’ll continue to pay the Part B premium. (And Part A, if you’re one of the few people who is not eligible for premium-free Part A.)

One of the most attractive things about a Medicare Advantage plan in Texas is the cost. You’ll find many MA plans on the market for $0 premiums. Don’t let that fool you into thinking it’s free. Remember, you still pay the Part B premium, plus you’ll have other copays and coinsurance costs dictated by the plan.

Medicare Advantage plans are managed care plans. They focus on routine care to prevent major medical conditions and also have some rules that require members to try cheaper forms of treatment or medication before relying on more expensive methods.

There are a handful of types of Medicare Advantage plans, and you’ll want to understand how each one works before choosing the one that’s right for you. One popular type is a Health Maintenance Organization (HMO).

If you enroll in an HMO plan, you’ll need to choose a primary care physician. That physician will coordinate all your care, including any specialist referrals. They’ll work with other providers within the HMO network to ensure you get the care you need. However, you’ll need to stay within the plan’s network to have benefits. If you require a provider outside of the network, you will not have coverage under your insurance plan.

Preferred Provider Organizations (PPOs) are another popular option. Their copays are usually a bit higher than HMOs, but you’ll have more freedom to choose your providers, and you’ll have coverage outside the plan’s network.

Medicare Advantage Coverage and Benefits

We can’t say exactly what the out-of-pocket costs are in these plans because there are hundreds of them on the market, each with an entirely different benefit package.

You will have copayments and coinsurance costs that will be based on what kind of service you’re getting. Each time you visit a doctor or specialist, you’ll have a small copay due. If you require an inpatient hospital stay, you’ll pay a certain amount for each day of your stay. Most Part C plans only make you pay for the first few days, after which the insurance carrier picks up all the costs.

Part C plans in Texas also come with maximum out-of-pocket limits or MOOPs. For example, your plan might have a MOOP of $4,500. Once you’ve paid this amount in coinsurance expenses, all approved services will be covered at 100%.

Another appealing aspect of these plans is that they usually include extra benefits. The plan may offer prescription drug coverage, gym memberships, transportation to doctor visits, meal delivery after a hospital stay, dental care, eyeglasses, hearing aids, etc. Some even give you an allowance for over-the-counter medications.

Don’t enroll in Medicare Advantage just for the extra benefits. Be sure to thoroughly review the medical coverage and make sure your doctors are in the plan’s network of providers.

Medicare Advantage Eligibility

Anyone who is enrolled in both Part A and Part B can choose to enroll in a Medicare Advantage plan offered in their zip code. Some MA plans, called Special Needs Plans (SNPs), have additional eligibility requirements that revolve around chronic conditions and Medicaid.

If you’d like to learn more about your Medicare Advantage options in Texas, speak to one of our licensed insurance agents at Cover Mile. We’ll teach you how each part of Medicare works, and we’ll take the time to learn more about you and what kind of coverage might best suit your needs.