Medicare Advantage

Medicare Advantage plans were created under the Balanced Budget Act of 1997 and signed into law by President Bill Clinton. These plans are commonly called Part C of Medicare. Some doctor’s offices call them replacement plans, more on that below.

Medicare Part C

Medicare Part C plans and Medicare Advantage plans are the same thing.



Medicare Advantage

Advantage plans for Medicare fall under Part C. These plans often have networks and some plans may require you to get referrals to see a specialist.
Congress designed this program to give Medicare beneficiaries a lower-premium option than Medigap. They also have very little Medicare underwriting. This means they are a coverage option for people who missed their open enrollment window for Medigap and now cannot qualify for Medigap due to health conditions.

Medicare Advantage plans, also known as MA are NOT similar to Medigap plans — they are different. Members get their benefits from a private insurance company instead of original Medicare. As we mentioned, sometimes you'll hear them referred to as Medicare replacement insurance.

Medicare is not really a fan of this language because it's not entirely accurate. You never permanently replace your Medicare when you join a Medicare plan. Instead you are just choosing to get your benefits from a private company for the rest of the calendar year.

How Medicare Advantage Works

A Medicare Advantage plan is a private Medicare insurance plan that you may join as an alternative way to get your Part A and Part B benefits. When you do, Medicare pays the plan a fee every month to administer your Part A and B benefits.

You must continue to stay enrolled in both Medicare Part A and B while enrolled in your Medicare Advantage plan. Medicare pays the Advantage plan company on your behalf to take on your medical risk. This is how Medicare Advantage plans are funded.

You will present your Advantage plan ID card at the time of treatment. Your providers will bill the plan instead of Original Medicare. Again, this is also why some providers consider them Medicare replacement plans, but it’s important to remember that you can always return to Original Medicare during a future annual election period.

Medicare Advantage Plans

Medicare Advantage plans have networks of doctors you must use when seeking medical care. Some networks are less strict than others.
You pay copays for approved services up to the out-of-pocket maximum. The OOP can be as high as $7,550. Part D costs not included.
Each Advantage plan has its own summary of benefits. This summary will tell you what your copays will be for various healthcare services. Your plan will offer all the same services as Original Medicare, such as doctor visits, surgeries, labwork and so on.
You might pay $10 to see a primary care doctor. Specialists will often be more — a $50 specialist copay is quite common. Some of the higher copays may come in for diagnostic imaging, hospital stay, and surgeries.
You can usually expect to spend several hundred on copays for these items. However, this varies greatly between states, so review plans in your area to get the specifics.
One neat thing about Medicare Advantage plans is that some of them offer minor benefits for routine dental, vision or hearing. Some plans include gym memberships. When searching for Medicare Advantage plans with dental and vision, our experts here at Boomer Benefits can help you compare those ancillary benefits between carriers.

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