Refresher for Navigating Medicare Advantage

During the Annual Enrollment Period, Medicare beneficiaries can change their coverage. This is a very important time of the year for beneficiaries enrolled in Medicare Advantage plans. We’ll discuss what Medicare Advantage plans cover, when you can make changes.

Medicare Advantage refresher

Medicare Advantage (Medicare Part C) plans are an alternative way to receive your Original Medicare benefits from a private insurance company. These plans must cover everything under Original Medicare and have a maximum out-of-pocket, but they have their own schedule of benefits and the items and services they cover.

Many of these MA plans include prescription drug coverage and benefits that Medicare doesn’t, such as routine dental, vision, and hearing coverage. In addition, they can include plan extras such as transportation, flex cards, and gym memberships at no additional costs.

Types of Medicare Advantage plans

These plans have a few different structures to choose from. Since private health insurance companies administer Medicare Advantage plans, they have additional rules for using them. Most of these plans are network-based HMO or PPO plans. In an HMO plan, you must use in-network providers except for in emergencies. PPOs allow you to see out-of-network providers, but you’ll pay a higher cost.

Health Maintenance Organization (HMO)

HMO plans are the most restrictive regarding networks and authorizations. Most HMOs don’t only require you to use in-network providers, except for emergencies. In addition, you must see your primary care physician to get a referral to see specialists and for tests. These plans typically have lower costs, and maximum out-of-pocket limits compared to other MA options.

Preferred Provider Organization (PPO)

When you enroll in a PPO, you can choose your providers, but if you have services out of the plan’s network, you’ll be subject to higher copays, and out-of-pocket costs for these out-of-network services. In addition, in most cases, you won’t need a referral to see a healthcare specialist.

Private-Fee-For-Service (PFFS)

PFFS plans work slightly differently. These plans can either include a network or have no network. When enrolling in a PFFS plan, you should show the plan information to the healthcare provider before services. You can use any Medicare contracted healthcare provider. However, the doctor must accept the terms and conditions of the plan before service.

Refresher on Medicare Advantage plans for Medicare beneficiaries with special needs

Medicare Advantage plans are designed specifically for beneficiaries with certain circumstances. Most of these plans are HMOs; however, some are PPO-style, depending on where you live. There are three special needs plans: chronic, dual, and institutionalized.

Chronic Special Needs Plans (C-SNP)

C-SNP plans are designed to help Medicare beneficiaries with specific chronic health conditions. The most common are COPD, diabetes, and heart conditions. These plans typically have lower copays for specific services, and medications catered towards treating the health condition.

Dual Special Needs Plans (D-SNP)

There are D-SNP plans for low-income beneficiaries who qualify for Medicare. These plans work together with Medicaid to help cover the costs of healthcare services for these lower-income beneficiaries. These plans typically have the most transportation, healthy food cards, and otc benefits to assist Medicare beneficiaries who qualify for these D-SNP plans.

Institutional Special Needs Plans (I-SNP)

These I-SNP plans are for beneficiaries who are living in an institutionalized setting. These special needs plans have benefits catered towards beneficiaries living in an institution.

AEP timeline and importance

The Annual Enrollment Period starts on October 15th and ends on December 7th. During this time, Medicare beneficiaries can review the changes in their current plan, and consider the other plans available there. Next, we’ll cover things you should remember when considering your Medicare Advantage options during AEP.

Refresher how to review Medicare Advantage options

One of the most important things to consider when reviewing Medicare Advantage plans is your healthcare needs. No two people have the same situation, so choosing a plan that fits your needs is important, not one that a family member or neighbor likes. Some plans do a better job than others for certain items. Here are a few examples of what you may need to consider when reviewing these Part C plans.

  • Do you need transportation to get to healthcare visits?
  • Are your prescriptions covered and affordable on the plan?
  • Do your healthcare providers accept the plans?
  • Do you need additional coverage such as dental, vision, or hearing?

These four items are the most important for considering your healthcare needs. There are a few other things that beneficiaries may want to consider, such as:

FAQs

How many times can you switch Medicare Advantage plans during Annual Enrollment Period?

You can make as many changes as you want during the AEP. The last plan submitted before the end of the election period will go active on January 1st of the following year.

Does a Medicare Advantage plan automatically renew?

Each year, Medicare Advantage plans will renew automatically, except in cases where Medicare terminates the plan’s contract, or the insurance company discontinues it. You might be eligible for a Special Enrollment Period if the plan doesn’t renew.

Can you change Medicare Advantage plans during the year?

You can only change your Medicare Advantage plan during AEP or MAOEP. To make plan changes, you’d need to qualify for a Special Enrollment period outside these two periods.

Get help reviewing Medicare Advantage plans for AEP

It’s wise to enlist the help of a licensed insurance agent that specializes in Medicare. These agents have access to tools to make comparing options quick and seamless. Fill out our online rate form to view Medicare options available in your area.

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Written By:
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Lindsay Malzone, Lindsay Malzone is the Medicare editor for Medigap.com. She's been contributing to many well-known publications since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.
Reviewed By:
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Rodolfo Marrero, Rodolfo Marrero is one of the co-founders at Medigap.com. He has been helping consumers find the right coverage since the site was founded in 2013. Rodolfo is a licensed insurance agent that works hand-in-hand with the team to ensure the accuracy of the content.