Medicare Advantage may also be referred to as Medicare Part C, or “Medicare Replacement”. It is a form of private insurance designed to protect retirees from the potentially high costs of the gaps in Traditional Medicare Coverage (that is, Medicare Parts A and B). This private health insurance policy effectively replaces your federal Medicare benefits. Instead of the federal government paying out on your claims, the private insurance company which manages your policy will handle these claims instead.
Federal Regulations for Medicare Advantage
In order to protect seniors from being sold inferior health coverage, Medicare Advantage policies are closely regulated by the federal government. These laws ensure that your Advantage plan will have at least the same coverage as that offered by Medicare Parts A & B. Usually, though, your Medicare Advantage policy will include much more than that. It will likely come with benefits which protect you from Traditional Medicare coverage gaps. It may also come with a prescription drug plan (a MAPD).
Medicare Advantage Enrollment In Maine
In Maine, 27% of seniors have chosen to enroll in a Medicare Advantage program instead of choosing other Medicare health care options. That leaves 73% of seniors in Maine with either Original Medicare, a former employment healthcare plan, or some other type of health insurance.
|Plan Type||Enrollment Percentage|
|Local PPO Plans||13%|
|Special Needs Plans||11%|
|Regional PPO Plans||9%|
|Private Fee-For-Service Plans||5%|
|Other (Cost Plans, MSA’s, etc.)||3%|
Plan Coverage & Cost
Many different factors will come together to determine how much your Advantage plan will cost you. Age, tobacco use, Medicare enrollment status, and your zip code can alter whether your specific rates are higher or lower than average plans near you:
Most Popular Medicare Advantage Plans in Maine
If you want to get the most affordable and most effective Medicare health plan, you’re going to have to educate yourself about all of the available options in your area. But that’s going to take a lot of time and energy on your part. The smart thing to do is to unburden yourself by consulting our trusted experts here at Medigap.com. We have a massive, highly detailed database of Medicare Advantage providers in your area, and our 5-star ratings system organizes them for you in ways that make it easier to understand which providers are best suited to meet your needs.
Helpful Medicare Advantage Tips & Tricks
Doctor/Provider Network Restrictions
The reason that HMO plans are more popular than plans with a larger provider network, and therefore greater access to medical care, is because they are generally less expensive than PPOs or PFFS plans. It is important to do your research once you find a plan that fits your budget in order to determine whether or not you will have to change doctors in order to be covered by that plan. Also, keep in mind that your doctor could leave the network, or be dropped from the network, at any time. You should have contingency plans in place for if you lose your preferred doctor.
Where you generally need to get your care and services from for:
- HMO Plans – HMO plans are also known as Health Management Organization plans. These plans are less expensive, but you can only get covered care from a small network of pre-approved doctors, hospitals, and facilities. There are exceptions for emergency care, of course. Some HMO plans may even offer a PoS (Point of Service) exception for highly specialized care from doctors or facilities that are outside of your network. Getting non-emergency care from an out-of-network provider without a PoS exception will likely result in a rejected claim from your insurance company.
- PPO Plans – PPO plans are Preferred Provider Organization plans. The doctors, hospitals, and facilities that are in your pre-approved network are preferred, but not mandatory. You should be able to get some of your healthcare costs covered from out-of-network sources, but it may be more expensive than in-network care. You’ll have more freedom to choose your healthcare providers, but you’ll have to pay more for it monthly and per-instance with out-of-network providers.
- PFFS Plans – A Private Fee-For-Service plan usually comes with the affordability of an HMO plan but with more doctors and facilities to choose from. But there is one catch: they have to agree to your insurance company’s payment terms on a case-by-case basis. This means you may be 100% covered for one appointment, and get a claim rejected the very next week from the same provider. You’ll need to keep in touch with your preferred doctors, hospitals, and facilities and make sure beforehand that they accept your insurer’s payment terms before getting care if you want to keep costs affordable.
- Special Needs Plans – Special Needs Plans are usually reserved for seniors who have – wait for it – special needs. If your healthcare needs require specialized (and often expensive) treatments, procedures, and medical expertise, you may qualify for a plan that can help you get such care for a relatively affordable price. Your care provider network is about as restrictive as it would be with an HMO, and also provides exceptions for emergency care. In the event that the specialized care you need is outside of your approved network, you’ll need to work with your insurance company to get it from that particular provider.
Finding a doctor who accepts your Medicare Advantage plan:
- HMO Plans – Medicare Advantage HMO plans help keep costs down by restricting the pre-approved pool of providers near you. If you require out-of-network emergency care, there is almost always an exception that can be made. Out of network, non-emergency, unapproved care will likely result in a failed claim, however.
- PPO plans – With Medicare Parts A & B, you can basically see any doctor, visit any hospital, or get care from any facility that accepts Medicare (which is almost universally accepted everywhere). You’ll get very similar benefits with a Medicare Advantage PPO plan. Granted, out of network care will likely be covered for less than in-network care and will cost you more out of pocket. You may also pay more for your monthly premiums. But for some seniors, the freedom of choice is worth it.
- PFFS Plans – Medicare Advantage Private Fee-For-Service plans work the same way that they would with any other health care plan. You’ll need to contact your provider(s) in advance and make sure that they’re willing to agree to your insurance payment terms before getting care there, every single time, even if you’ve been there before. Naturally, there are emergency care exceptions. And the tedium may be worth it if a PFFS plan is the most affordable option in your area.
- Special Needs Plans – If you have a Medicare Advantage Special Needs Plan, you’ll have a similarly restrictive network of care providers to that of an HMO. But you’ll be able to get your special health care needs at a more affordable rate than most plans, and you’ll have exceptions for emergency care. Most SNP Medicare Advantage plans will include pre-approved doctors and facilities in your network that are highly capable of treating your specific medical concerns. But you still may be able to negotiate out of network care with your insurance provider if you feel you absolutely need it.
Drug, Vision and Dental Coverage
One Advantage that Medicare Part C offers over other supplemental insurance has to do with offering seniors one simple, comprehensive, streamlined policy. With Medicare Advantage, you can bundle your Traditional Medicare benefits, prescription drug coverage (medicare part D), and any additional benefits (such as vision and/or dental) all into your Advantage plan. There’s no need to deal with separate companies and different insurance plans.’
- With a Medicare Advantage plan, you will likely have the option to add additional forms of coverage that you wouldn’t get from Original Medicare or a Medicare supplement policy. One of those forms of coverage is vision care insurance. It will help reduce your costs for eye doctor visits and corrective lenses, but may come with certain restrictions on doctors and treatment. It may also raise your premiums.
- Medicare Advantage plans offer similar advantages with regard to dental insurance. But it will come with similar caveats, too. Many plans will charge you a higher premium for adding dental coverage, and you may only be able to get care from network-approved dental offices and oral surgeons.
Enrollment Options & Best Time To Enroll
Like most Medicare plans, Part C has different ways to qualify and enroll. Some companies, however, may require you to give information on your current health status or undergo an exam. For most seniors, you’ll likely be accepted for coverage despite any pre-existing conditions unless you have End Stage Renal Disease. But even those with serious conditions like ESRD can still find coverage. Your local insurance agent or your state department of insurance will have more information. You can also visit our Medicare Advantage Enrollment Options Page if you would like to learn more about the process.
- Initial Enrollment Period: 6-month timeframe when you first enroll in Medicare to purchase a Medicare Advantage plan.
- Annual Enrollment Period (AEP): This timeframe runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
- Special Enrollment Period (SEP): During special circumstances, you may be eligible to purchase/change a plan outside of the Annual Enrollment Period. Things such as moving out of the plans’ service area, losing group health or employer coverage, a company no longer offering plans in the area, etc. are all events that could trigger a SEP.
What Medicare Advantage Plan Is Best For Me?
If you choose to go with Medicare Advantage, there are a lot of things to worry about. It’s from a private health insurance provider, so you need to make sure that they are financially stable, provide excellent customer service, and have a good reputation for providing care. Unfortunately, the best plans are usually more expensive, and keeping costs low is equally important.
You don’t have a whole lot of time to make that decision, either. You’ll have to enroll within the enrollment period window or you’ll have a heap of trouble getting the affordable plan you want. Our goal is to provide seniors like you with the help and information you need to get the perfect Medicare plan. We encourage you to browse our site and to reach out to us so that we can connect you with the best Medicare insurance providers near you.