Important things to know about Medicare Advantage Plans.

  • Medicare Advantage plans can be a great way to cover the expenses not covered by Original Medicare. They are different than Medigap plans, and a bit more complex. Agents who offer them are required to be certified annually with course work and exams, something not required for Medigap plans.
  • There are several types of Medicare Advantage plans, including HMO, PPO, and PFFS.
  • For many plans, there is no monthly premium. These plans are not free, however. When you enroll in a Medicare Advantage plan, you continue to pay premiums for your Part B benefits.
  • They usually include a prescription drug plan. Getting an MA plan with drug coverage means you do not have to purchase a Stand-Alone Part D Drug Plan as you would with a Medigap plan.
  • Medicare Advantage HMO plans require you to receive all of your medical care - except in the case of an emergency - within a fixed network of doctors and hospitals. In these plans you have a primary care physician (PCP); to go to a specialist you may need to be referred by your PCP to a specialist who is in-network. This differs from a Medigap plan, which allows you to go to any doctor or hospital that takes Medicare, with no networks and no referrals required for specialist visits.
  • All Medicare Advantage plans are required to have an out-of-pocket limit. Should your co-payments reach the limit in a calendar year, all co-payments drop to zero for the remainder of that year. This limit varies by company.
  • If you try an Advantage Plan for the first time at age 65 and don’t like it for any reason during the first year, you may exercise your Trial Right. This allows you to change to a Medigap plan with guaranteed acceptance.
  • Medicare has strict rules on the way agents are allowed to interact with Medicare beneficiaries about Medicare Advantage plans. For any face-to-face meeting where MA plans are discussed your advance written consent is required on a “Scope of Appointment” form. This form may be mailed to you, or sent to you via email with your consent. The meeting cannot take place prior to the form being returned, and cannot be signed at the time of the meeting, with a few exceptions. Agents are prohibited from cold-calling you or door-to-door soliciting you to discuss Medicare Advantage or Part D prescription drug plans.

The information above is intentionally general rather than specific. The Center for Medicare has lengthy compliance requirements required for plan-specific information. Please call us if you have any questions about Medicare Advantage plans in general or any specific plan. We’re happy to help you determine whether a Medicare Advantage plan is the right fit for you.