What Is Medicare Advantage?

Published: Wednesday, July 25 2018
Last Updated: 3 months ago

A popular alternative many people have been turning to instead of Original Medicare is Medicare Advantage. If you are unfamiliar with it, you may be wondering what is Medicare Advantage. For those of you interested in turning to this program, the provided information will offer you greater details about it from how Medicare Advantage works, the costs of the plan, and more.

What is Medicare Advantage?

Before doing anything to change your healthcare coverage, perhaps one of the biggest questions on your mind is: what is Medicare Advantage? Medicare Advantage, otherwise known as Part C, is a type of healthcare plan that's offered through a private company. Medicare Advantage will generally provide your Medicare Part A and Part B coverage.

What Parts Does Medicare Advantage Include?

When begging the question about what is Medicare Advantage, it is important to focus on the actual benefits you may receive and how it is different than any other Medicare plan. Medicare Advantage, as previously stated, includes benefits from both Part A and Part B plans.

In general, Advantage is required to cover the services offered under Original Medicare with the exception being hospice care. All types of plans must include emergency and urgent care in addition to emergency care that is outside your coverage area (except outside the United States).

There are other benefits an Advantage plan can have such as vision, dental, andeven some prescription coverage (Part D), but those are not guaranteed.

Medicare Advantage Cost

The cost of an Advantage plan will depend on the type of plan you decide to have. Because each insurance company sets their costs differently, it is vital that you thoroughly understand your plan. For example, some Advantage plans have a $0 premium while others do not. With no premium, that can mean higher deductibles or copayments.

Another way premiums can affect your costs is whether or not your plan pays for any of your Part B monthly premiums. For deductibles, some plans may or may not have one. Whether or not a plan charges a copayment will come into play with costs as well. Also, if you decide to go for extra benefits, the costs of your plan will certainly change.

How Medicare Advantage Works

With an understanding of what is Medicare Advantage, it is time to break down exactly how Medicare Advantage Works. To begin, there are a number of different types of Advantage plans:

  • Health Maintenance Organization (HMO) Plans - With these types of plans, the majority of them offer a list of providers and hospitals in their network that you can use. Also, in most cases, you will need a referral if you need to see other specialists or have some tests done.
  • HMO Point-of-Service (HMOPOS) Plans - These are still HMOs, but with this specific type of plan, you may be eligible to see out-of-network services. This will come with higher coinsurance or copayments, however.
  • Preferred Provider Organization (PPO) Plans - This type of plan does allow you to see other doctors and hospitals that are outside the PPO network. However, if you seek healthcare within the network, you can see lower costs.
  • Private Fee-for-Service (PFFS) Plans - These plans hold similarities with Original Medicare plans in that you are allowed to see whatever doctor, specialist, hospital, etc. you wish. The only condition is that the person or hospital accepts the payment terms of the plan you have.
  • Special Needs Plans (SNPs) - With SNPs, individuals living with specific chronic conditions or in a nursing home facility can receive specialized healthcare.
  • Medical Savings Account (MSA) Plans - Using a plan like this requires a bank account. It works in a way that Medicare makes a monetary deposit into your account that you can use to pay for services during that year. This deposit is typically smaller than the deductible.

Another way to understand how Medicare Advantage works is by looking at the requirements. If you are eligible for Original Medicare, then you are eligible for an Advantage plan. However, you must have Part A and Part B coverage, in addition, to actually living in the area that the plan services. Usually, however, those with End-Stage Renal Disease (ESRD) are not eligible for an Advantage plan.

Medicare Advantage Pros and Cons

It is not unheard of for a healthcare plan to have advantages and disadvantages. To help you decide whether or not a Medicare Advantage plan is right for you, it is useful to address the pros and cons.

Medicare Advantage Pros

  • More Costs Savings - One of the more prominent benefits to having an Advantage plan is that you can save more money. There are a number of Advantage plans that have a $0 or just a low monthly premium. Some plans may or may not have a deductible. This gives you a bit more freedom in choosing which plan better suits your budget.
  • Additional Benefits To Use - Another major perk in signing on for an Advantage plan is that you can see coverage for services that other plans do not have. For instance, you may see coverage for assisted living, dental, vision, and more. Original plans do not usually cover all of this. Also, though this is not true for all Advantage plans, some plans offer abroad coverage if you are outside the U.S.

Medicare Advantage Cons

  • Some difficulties getting procedures covered. - Although you can see benefits you may not have with Part A or Part B coverage, depending on the Advantage plan, you may have trouble getting certain procedures covered. This is due to the fact that Advantage plans try to keep costs down for your sake. If you are in need of multiple procedures like surgeries or medical equipment, you may be forced to seek prior authorization, something that can complicate matters.
  • Restrictive network in many cases. - Even with some Advantage plans allowing you to seek out-of-network services, there is little breathing room in general when choosing a provider or hospital. A lot of this is based on where you live, which is not the case if you were to just have Original coverage which allows you to see any provider or hospital that accepts Medicare.