Key Takeaways
- Research Medicare Advantage plans by provider network, prescription drug coverage and annual out-of-pocket expenses.
- Many Medicare Advantage plans combine dental, vision, hearing, fitness and prescription coverage into a single plan.
- Before joining a Medicare Advantage plan, check out the process of referral and doctors that are already in the network.
- To determine which Medicare Advantage plan is most suitable for your health care needs, compare Star ratings, premiums, copays and deductibles.
- Don’t miss coverage gaps and late penalties by enrolling outside of Medicare Open Enrollment or Initial Enrollment.
Introduction
When seniors select a Medicare Advantage plan, they can easily compare coverage plans, prescription coverage, provider networks, and monthly costs.
Medicare Advantage plans are made up of hospital insurance, medical insurance and additional coverage like dental and vision care in Part C plans.
This guide outlines how to compare Medicare Advantage plans, understand the costs of Medicare Advantage plans, understand provider access to Medicare Advantage plans, and choose the best Medicare Advantage plans for long-term healthcare needs.
What are Medicare Advantage plans?
Medicare Advantage plans are private insurance plans covered by Medicare. These plans are an alternative to Original Medicare that offer Medicare benefits. Medicare Advantage plans generally cover hospital, physician, preventive, emergency, and prescription drug benefits within a single plan, and will often cover emergency care anywhere in the country.
Part A is Medicare Part A and Part B is Medicare Part B. Part A is for hospital care, and Part B is for outpatient, or medical, care like doctor visits and preventive care. Most dental care, hearing aids, fitness programs and routine vision services are NOT covered under Original Medicare.
These extra benefits are typically offered with a Medicare Advantage plan. The majority of Medicare Advantage plans have annual out-of-pocket maximums. There’s no cap on how much Original Medicare will spend each year. This financial security is one of the reasons why seniors opt for Medicare Advantage plans.
Learn more about Medicare
Medicare is a government health insurance program available to individuals age 65 and above, people with certain disability qualifications and to some ESRD (End-Stage Renal Disease) patients. Medicare eligibility typically only starts when a person turns 65 during the Initial Enrollment Period.
There are four main components to medi care:
- Part A for hospital insurance
- Part B for medical insurance
- Part C for Medicare Advantage plans
- Part D for prescription drug coverage
Late enrollment penalties may apply to those without coverage on COBRA or employer insurance who do not enroll. The official information on Medicare enrollment and plan comparison is on Medicare.gov and CMS.gov.
Get more with a Medicare Advantage plan
Medicare Advantage Plans offer additional benefits beyond what is covered by Original Medicare. Benefits can be transportation, Over-the-Counter (OTC) benefits, telehealth services, meal delivery upon discharge from the hospital, gym memberships, wellness programs, and hearing aid allowances.
A Medicare Advantage plan might be able to save Medicare beneficiaries money when they need frequent medical appointments, ongoing care for chronic health problems, or prescription coverage. Some plans have programs to coordinate the communication of doctors, hospitals and specialists.
| Plan Type | Main Feature | Best For |
|---|---|---|
| HMO | Requires network providers | Lower monthly costs |
| PPO | Allows out-of-network care | Frequent travelers |
| SNP | Designed for chronic conditions | Special healthcare needs |
| PFFS | Flexible provider access | More provider choice |
Comparing the different types of Medicare Advantage plans
| Plan Type | Main Feature | Best For |
|---|---|---|
| HMO | Requires network providers and primary care doctor referrals for specialists. | Lower monthly premium costs. |
| PPO | Allows out-of-network care, offering greater flexibility without strict referrals. | Frequent travelers and snowbirds. |
| SNP | Designed specifically for institutional requirements or chronic medical conditions. | Special healthcare needs. |
| PFFS | Flexible provider access based on doctors accepting plan payment terms. | More personal provider choices. |
Under Health Maintenance Organization (HMO) plans, members are required to seek healthcare in a network of doctors and hospitals except in emergency situations. Some HMO plans may require a referral to specialists. Generally, premiums are lower with HMO plans.
Preferred Provider Organization (PPO) Plans are more flexible. PPO members are able to access hospitals that are not in the network, but in cases they choose to visit a non-network provider, they would incur higher out-of-pocket expenses. PPO plans are popular among travelers and snowbird retirees who live in several different states.
Private Fee-for-Service (PFFS) plans are available to members who can see providers who accept to see them for the terms outlined by the plan. Medical Savings Accounts are high-deductible coverage combined with a savings account to pay for medical costs. Special Needs Plans (SNPs) are created for individuals who have an institutional care requirement, chronic condition, or dual Medicaid and Medicare enrollment.
SNPs specialize in integrated, comprehensive care for those with complex health care needs. By comparing these Medicare Advantage plans in detail, seniors can avoid any problems with networks or referrals that they might encounter in the future.
Compare common Medicare Advantage plans side by side
Side-by-Side Evaluation Criteria
Healthcare Plan types meet different healthcare scenarios. HMO plans are good for those that are not afraid of going through their local provider networks or primary care physicians for referrals. PPO is better for people who retire with plans for frequent travel or a desire to see more doctors.
Some plans emphasize the low monthly premiums, and some offer more robust prescription coverage. Different insurers have different copays, specialist copays, and hospital costs. Medicare’s star ratings judge the quality of care a plan provides to customers through a range of quality metrics including customer satisfaction, preventive care management, treatment of chronic disease and complaints.
Five-star plans tend to be more satisfied and have higher quality health care ratings. When you compare Medicare Advantage plans side-by-side, you should look at the following:
- Monthly premium costs
- Deductible amounts
- Out-of-pocket maximums
- Prescription drug tiers
- Specialist copays
- Provider network size
- Star ratings
- Extra benefits
What to consider in a Medicare Advantage plan?
Medicare Advantage plans are a good option for those who prefer an integrated health care system, have a fixed budget, travel often, use several different medications, and want to see their doctor.
Coverage for prescription drugs (Part D)
⚠️ Critical Form Check for Chronic Conditions
- Drug Tier Placement: Confirm if your routine medications fall into high-cost specialty blocks.
- Preferred Pharmacies: Cross-reference pharmacies to minimize retail copay markup.
- Prior Authorization Rules: Check constraints before taking enrollment to prevent care delays.
- Quantity Limits: Verify restrictions on ongoing monthly maintenance supplies.
One of the top things to consider when comparing Medicare Advantage plans is prescription drug coverage. The majority of Medicare Advantage plans offer Part D prescription drug coverage. Each drug plan has its own list of medications known as a drug formulary, and plans may have different lists.
Reflect on the following for individuals with a chronic condition:
- Drug tier placement
- Monthly prescription costs
- Preferred pharmacies
- Prior authorization rules
- Quantity limits
Low premium plans may come with high prescription drug copays. Checking the coverage of medications prior to enrollment helps to avoid any late rewards.
Referral requirements for specialist care
Numerous HMO plans have a requirement for referrals before an appointment with a specialist. In PPO plans, referrals are typically not required for the use of specialists.
PPO plans might be the best option for individuals with chronic diseases or multiple specialists as delays in referrals can impact care coordination. For transplant, cancer and those with chronic conditions, the rules of referral are important.
Contracted network of doctors and hospitals
All Medicare Advantage plan(s) rely on provider networks. Important for seniors to verify that the doctors, hospitals and specialists of their choice are included in the network before taking enrollment.
Network size is important for rural retirees because services for providers may not be available in rural areas.
For some smaller plans, the provider networks are limited, limiting access to specialists. Be sure to look at provider directories carefully as network participation usually changes annually.
Ability to use doctors or hospitals outside of network
PPO plans offer greater flexibility when it comes to out-of-network care. HMO plans typically limit care outside of the network for non-emergency care. For travelers, snowbirds and retirees who split their time between two states, it may be more convenient to select a PPO plan, which allows access to a wider network and may minimize the disruption of travel.
Medicare Advantage plans include emergency care across the country, although routine non-emergency services might not be covered outside of network regions.
Star ratings
Medicare Star ratings provide consumers with a way to compare the quality of Medicare plans. The rating for the stars is given from 1 to 5. A higher rating typically means higher customer satisfaction, better preventive care performance, and care coordination.
To compare plans with similar costs and benefits, it can be helpful to compare their star ratings. Members tend to have stronger complaint resolution scores and are better retained in plans with high ratings.
Medicare Plan Finder and NerdWallet have popular tools that often feature the best Medicare plans at certain times of year, especially during the open enrollment season.
Find the best Medicare Advantage plan for you
Every individual’s health care needs is unique, and the best Medicare Advantage plan is determined by these needs. If you’re a retiree who has few medical costs each month, you might want to consider the lowest premiums available. If someone has a chronic disease, they might be more interested in provider networks, prescription coverage, and access to specialists.
It is important to review the plan details on an annual basis as costs, networks and benefits are subject to change each year. When it comes to Medicare enrollment, comparing plans during open enrollment will help you prevent any surprises.
| Feature | Original Medicare | Medicare Advantage |
|---|---|---|
| Provider Choice | Nationwide access | Network-based access |
| Prescription Drugs | Separate Part D needed | Usually included |
| Extra Benefits | Limited | Dental, vision, hearing |
| Out-of-Pocket Limit | No annual limit | Annual spending cap |
5 Steps to Choosing the Right Medicare Plan for You
When selecting a Medicare plan, you must balance healthcare requirements, budget, prescription expenses and access to physicians. Many elderly are only concerned about spending premiums, but not the annual cost of health care. It’s better to have a better grasp of coverage details prior to enrolling.
1. Know what to do—and when
Enrollment timing matters. Enrollment periods may be missed, which can result in penalties or a delay in coverage. The IEP typically opens three months before the child’s 65th birthday and lasts for 7 months.
Annual Open Enrollment is October 15 – December 7 annually. This time of year is when Medicare beneficiaries get to enroll in or sign up for Medicare plans.
2. Check for help with paying for Medicare costs
Medicare Savings Programs, Medicaid assistance or prescription drug assistance programs may be eligible to beneficiaries with low incomes.
Financial assistance can lower premiums, deductibles and copays. Dual eligible beneficiaries may be eligible for Special Needs Plans that provide coordinated care and reduced health care costs.
3. Decide between original Medicare and Medicare Advantage
Original Medicare provides more access to providers across the country and is typically paired with a Medicare Advantage plan and/or a Medigap plan. Medicare Advantage plans offer several services in one plan and have caps on how much they will spend annually.
Those who need to see a doctor whenever they want or are moved to travel often may opt for Original Medicare with Medigap coverage. People aged and older who prioritize low premiums and combine benefits with Medicare Advantage plans.
4. Compare policy coverages and price
When comparing policy coverages, it’s important to look at deductibles, specialist copays, drug formularies, hospital cost, dental benefits, hearing coverage, and telehealth services.
A plan that has a lower premium can lead to higher annual expenses in the form of copays and limited provider options. Monthly premiums are not the only costs of total healthcare.
5. Select and enroll on time
Enrollment should be done before deadlines and enrollment should be carefully compared. Late enrollment can result in late fees and gaps in coverage. Carefully read the confirmation notices after enrollment, to make sure coverage is correct.
Compare Original Medicare & Medicare Advantage
Original Medicare and Medicare Advantage have different benefits, provider access and out-of-pocket coverage.
Doctor & hospital choice
Original Medicare lets patients go to almost any provider in the country that will accept Medicare. Medicare Advantage plans are based on contracted provider networks.
Cost
Medigap and Medicare Part D coverage may be needed for Original Medicare. Medicare Advantage plans may bundle services into one monthly premium.
Coverage
Dental vision fitness hearing benefits are not always covered by Original Medicare, but they are typically a part of a Medicare Advantage plan.
Foreign travel
Most Medicare Advantage plans offer only limited coverage for going abroad. There are some Medigap plans that have improved emergency coverage for people outside of the country.
What do you want to do next?
Beneficiaries should do research on available plans, check provider networks, estimate the yearly expenses for healthcare, and sign up before deadlines.
why a Medicare Advantage plan might be right for you
One reason many seniors opt for Medicare Advantage plans is the combination of healthcare services and financial protection are merged into one plan. Lower or $0 premium payments each month will lower fixed retirement costs. Spending limitations on a yearly basis keep health care costs from being unlimited.
Dental, vision, fitness and hearing coverage is available that Original Medicare doesn’t offer. Prescription drug coverage is included and makes a convenient part of your insurance. Because one plan is so easy to use, there is less paperwork and confusion about billing.
Facilitating referrals to providers and/or specialists enhances coordinated care across provider networks. The emergency care across the country is available to travelers and retirees during their stay outside the area where they normally live. Care coordination for seniors with chronic conditions enables them to get the most out of treatment.
Summary
