Medicare Advantage plans

What are Medicare Advantage plans?

Medicare Advantage Plans (also known as Medicare Part C) are insurance offered by private insurance companies that provide the coverage associated with Original Medicare (Parts A and B).  Most plans will include prescription drug coverage, while many include additional benefits not available through Original Medicare.  Some examples of additional benefits include coverage for dental, vision, hearing (including hearing aids), gym membership, naturopathy, other-the-counter health product allowances, transportation assistance, etc.

How do Medicare Advantage plans work?

Medicare Advantage Plans are regulated by CMS (the Centers for Medicare and Medicaid Services).  The plans are required to cover all the same benefits provided by Original Medicare.  CMS pays the insurance company money to administer these benefits (basically a form of subsidy, which reduces the costs of coverage).  This is why some plans may have a premium as low as ZERO.  A majority of Medicare Advantage Plans can reduce many of the routine costs associated with medical care and more importantly provides a cap in potential out of pocket costs.  Original Medicare does not offer any cap on Max Out-of-Pocket costs.  Some Medicare Advantage Plan that include prescription coverage costs less per month than some stand alone prescription drug plans.

What are the Qualifications for Enrolling in Medicare Part C?

The following are the only requirements for enrolling in a Medicare Advantage Plan as of 2021 (the exclusion for someone with End Stage Renal disease will be eliminated):

  1. Enrolled in Original Medicare (Part A and Part B)
  2. Live in the Plan's service area

Both of these must be true.  Residence is generally determined by where someone is registered to vote and lives at for a majority of the year (greater than six months).  If someone lives in Arizona for 4-5 months of the year, while living in Washington the remainder of the time, they are required to obtain a plan that's valid in the County they live in while in Washington.

Just like selecting a Medigap Policy, if someone want's a Medicare Advantage Plan, they must continue to pay any applicable Part A and/or Part B premiums.


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What are some of the different types of Medicare Advantage plans available?

HMO's are Health Maintenance Organizations.  There are two types:  Close panel HMO's where you must use their doctor's and facilities all owned by the HMO.  Open panel HMO's contract with the major providers in their service area for care, often offering more choices.  Most HMO's require referrals and some offer travel benefits.  In Network providers must be used.

PPO's are Preferred Provider Organizations.  They do have a preferred network of contracted providers.  Some PPO's utilize regional networks, while others offer Nationwide networks.  Referrals are not required and care can be sought outside the network at a higher cost.  Many offer travel benefits.  These plans will generally be more expensive than comparable HMO's.

SNP's are Special Needs Plans.  The primary SNP most widely available are the Dual Special Needs Plans (DSNP).  Enrollment in these plans are usually restricted to those eligible for both Medicare and Medicaid.  Most DSNP's currently available in Washington State are open panel HMO's.  They will give qualified individuals enhance benefits in addition to current coverage.

What are the different Medicare Advantage programs?