Medicare Advantage Plans

Medicare Advantage plans are health plans sold and marketed by private insurance companies as alternatives to traditional Medicare, sometimes referred to as Medicare Part C. Medicare Advantage providers contract with Medicare to provide these services for participants and must follow the directives set forth by Medicare in order to receive reimbursement for your care. Medicare-approved plans are a good deal for seniors interested in receiving a total package of care including Part A hospital insurance and Part B medical or doctor’s coverage; Part D prescription drug coverage is often provided at no cost along with limited dental and vision benefits.

Types of Medicare Advantage Plans

Medicare Advantage plans follow individual rules governing out-of pocket costs as well as the way in which services are provided by doctors and facilities, subject to change each year. The following are the three most common types of Medicare Advantage plans currently available:

Health Maintenance Organization Plans – HMOs offer the best value with coordination of care and focus on prevention however; one is restricted to using only the doctors, hospitals and providers within the plan network with the exception of emergent or out of state urgent care. Generally, if you go outside the network, services will not be paid for. Most HMO plans require participants to choose a primary care doctor, a referral for care by a specialist and prior approval for specific services.

Preferred Provider Organization Plans – Regional PPOs offers coordination of benefits and discounts through a network of providers along with the flexibility of obtaining care from any doctor or facility at a higher cost.

Private Fee for Service Plans – PFFS plans are the most flexible in which one may choose any doctor or hospital approved by Medicare that accepts your Medicare Advantage plan’s conditions as well as Medicare. With PFFS plans acceptance of a plan member may be determined on a per visit basis while additional premiums for extra services can prove costly.

Pros and Cons of Medicare Advantage Coverage

Medicare Advantage plans are required to cover all basic medically necessary services though each may include widely divergent monthly premiums, deductibles, co-pays and co-insurance as part of the cost of a specific procedure. Additional services may be limited to preventative care, dental and vision care or simply a health club membership as part of the plan. Some plans may charge more for critical services and hospitalization, while others may limit skilled nursing care and contain spending limits each year.

A word of caution: It is essential to compare the costs and benefits of the Medicare Advantage plans offered in your area, as monthly premiums may be lower; however, out-of-pocket costs may increase.

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