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Medicare Advantage Plans

Medicare Advantage Plans (aka Medicare Part C Insurance)

work as your primary insurance to replace Medicare A and B (however, you are still responsible for paying your Medicare Part B premiums).

Medicare Advantage Plans are an “all in one” plan that can include Prescription Drug Benefits and even some ancillary benefits like dental, vision, hearing, and gym memberships.

All Medicare Advantage (MA) plans must cover all Part A and Part B benefits.  Most MA plans also cover part of the Original Medicare cost sharing benefits.

Certain chronic health conditions and/or low income may qualify you for a Specials Needs MA Plan.

Differences between MS and MA – 15 mins

For more information, please read this article published by Forbes Magazine in 2022 titled: Why Are Medicare Advantage Plans So Heavily Advertised?

Shopping MA Plans – 6.5 mins

What to look for when shopping Medicare Advantage Plans

All Medicare Advantage Plans work differently.  Although there are various comparison softwares available to to a high level comparison, only the formal Summary of Benefits and Evidence of Coverage documents provided by the different insurance companies tell the full story of how each plan works and the benefits provided.

  • What type of network coverage?  HMO, PPO, etc
  • Do your providers accept the plan?
  • Copays of various services
  • Extra Benefits
  • Prescription Benefits

Network Based Coverage

Medicare Advantage Plans have their own doctor networks.  There are various types of network arrangements to choose from: HMO, PPO, PFFS, MSA.

Networks may be regionally based.  It is important to know if you travel regularly or have multiple residences when choosing a proper plan.


HMO enrollees must generally use doctors and hospitals within the plan’s network to receive covered services.  Unless you are receiving emergency services and you are outside of your plans servicing area, there is likely no coverage if your provider does not participate with the plan.  You will have to pick a Primary Care doctor, and you may need referrals for specialists (many plans do not require referrals for most specialists).

  • If you want drug coverage, you must take the drug coverage offered with the plan.  You cannot purchase a standalone drug plan.

PPO Plans offer both in and out of network benefits.  With a PPO plan, you can see any doctor who accepts Original Medicare; however, you will pay more if the provider is not your specific plan’s network.  Typically there are lower copays if you stay within the network, and a higher percentage of cost (coinsurance) if you go out of network.  You are not required to pick a Primary Care Provider and do not need referrals for in network services.

  • If you want drug coverage, you must take the drug coverage offered with the plan.  You cannot purchase a standalone drug plan.
PFFS-Private Fee For Service

May receive covered services from any provider in the US who is eligible to provide medicare services and agrees to accept the plan’s terms and conditions of payment.  Except for emergencies, enrollees must inform providers before they receive services that they are a PFFS plan member so the provide can decide if they want to accept their coverage.  Cost sharing may include balance billing up to 15% of the Medicare allowable rate.

  • If you want drug coverage, you can take the coverage if offered with the plan.  Otherwise, you can get a PFFS plan without drug coverage and purchase a standalone drug plan.

A Medicare MSA is a high deductible health plan which is combined with a savings account used to pay for healthcare expenses.  Medicare contributes some money toward to the beneficiary’s savings account.  MSA enrollees pay for health care expenses from the savings account and then out of pocket until the annual deductible is met, after which the plan pays 100% for covered services.  MSA plans may not have a network or may have a full or partial network of providers.

  • MSA plans do not offer drug coverage.  You must enroll in a standalone drug plan if you want drug coverage.

Copays and Out of Pocket Limits

Premiums for Medicare Advantage plans are typically lower than Medicare Supplement premiums, but they may have higher maximum out of pocket limits.  In 2022, the Maximum In Network out of pocket limit that can be on any plan is $7,550 (and $11,300 out of network).  Out of Pocket limits may be lower depending on plan.  Most plans have a schedule of copays that you will pay depending on each covered service until you reach your Maximum Out of Pocket (MOOP).

Many plans have a copay/coinsurance of 20% for chemotherapy and Part B drugs.  This is likely to be your biggest expense in a Medicare Advantage plans.

Your Part D prescription costs do NOT count toward your out of pocket maximum.

Do all of your providers accept the coverage?

It is imperative that we check the plan’s participating provider list to make sure your doctors participate with the coverage.  It is important to know that each plan can have a different network (so even if you are looking at 2 different plans with the same insurance company, they may have 2 different lists of participating doctors).

Providers enter and exit networks based on their contract -not the plan year.  This means that providers may enter or exit a network mid plan year.  This does not give you a special enrollment period to change plans.  You can only change Medicare Advantage plans during the annual enrollment period.

Please be prepared with a complete list of your preferred doctors and hospitals for any phone appointment that may be shopping your coverage.

Shopping Extra Benefits

Some plans include extras like Dental, Vision, Gym Memberships, Hearing Aides, OTC Medications, etc.  If you see any benefits advertised on TV that may be important to you, be sure to mention them.

Be mindful–even if a plan lists that it has coverage, for the extra benefits, it is important to review the Summary of Benefits and/or Evidence of Coverage in detail to view the restrictions.

If you think you are interested in Dental Benefits, ask your dental provider if they participate with Medicare.  Many of the plans that offer dental require that the dentist participate with Medicare.  Don’t worry if your dentist does not work with Medicare, there are also standalone dental plans available (at additional cost) that may have broader networks.

Re-Evaluating your Plan

Changing to Medicare Supplement: We recommend that you check in within the first 6 months you are on your first Medicare Advantage plan to let us know how you like the coverage.  If you decide that you would rather go with a Medicare Supplement Plan, you will have the most options available to you in the first 6 months.  However, there may be limited options available within 12 months depending on your circumstances.  After 12 months, you will be able to go back to Original Medicare, but a qualifying for a Medicare Supplement plan will depend on medical underwriting.

Changing to a different Medicare Advantage Plan: The Annual Enrollment Period (10/15 to 12/7) and the Medicare Advantage Open Enrollment Period (1/1 to 3/31) is the only time you can change your Medicare Advantage Plan.  You can change annually with no medical underwriting.  Besides that, you are locked in to an annual contract.

When Can I Change my Plan – 4.5 mins