Medicare Advantage

Medicare Advantage, also known as Medicare Part C, are privately managed senior health insurance plans. Carriers that Medicare Advantageparticipate in the Medicare Advantage program must submit their plan designs to CMS for approval. Georgia Advantage plans change almost every year with some plans being discontinued and in some cases, new plans appear as replacements.


Is Medicare Advantage For You?

Medicare Advantage plans are private health plans that generally provide all the coverage of original Medicare. Almost all Medicare Advantage plans have strict doctor and hospital networks. If you fail to utilize participating providers your out of pocket expenses will be considerably greater than using par providers.

Many Georgia doctors do not participate in ANY Medicare Advantage plans. Others may accept patients with a Cigna plan but not Humana and Blue Cross. If you enroll in an Advantage plan you must check your current doctors and prescription medications every year during open enrollment against next years list of participating providers and drug formulary.

Most (but not all) plans also include Medicare Part D prescription drug coverage. These plans are referred to as Medicare Advantage with Prescription Drug (MAPD) coverage.

Below are types of Medicare Advantage plans:

  • Medicare Health Maintenance Organization (HMOs)
  • Preferred Provider Organizations (PPO)
  • Private Fee-for-Service Plans
  • Medicare Special Needs Plans

Medicare Advantage plan availability is determined by your home zip code. Just because your cousin Mary in Macon loves her BCBSGA Advantage plan does not mean the same plan will be available in Savannah where you live. Even if the same plan is available, don’t assume your doctors and hospitals are participating providers.

Medicare Advantage Disadvantages

Medicare Advantage Plans have more restrictions and fewer choices than original Medicare and a Medigap plan.

  • If you change to a Medicare Advantage Plan you may find that the doctor you have been seeing for years does not participate in your new plan and will only see you on a cash basis.
  • Medicare Advantage Plans typically have low premiums, in some cases $0. The trade off is higher out of pocket when you need it most.
  • Traditional Medicare and a comprehensive Medigap plan F supplement typically means you have $0 out of pocket for hospital and doctor bills when approved by Medicare.
  • When you have a Medicare Advantage Plan, private insurance carriers, not Medicare, decide which claims will be paid and which will be denied.
  • A large hospital bill that is approved by your Medicare Advantage carrier may leave you owing $3,000 or more once the dust settles.
  • When you want to see a specialist you must first have a referral by your PCP (primary care physician) and that referral must be approved by your Advantage carrier.
  • The rules for Medicare Advantage plans change every year

Medicare Advantage Advantages

To be fair, there are positive things about Medicare Advantage Plans.

  • Advantage plans may include “extra” benefits such as limited vision or dental coverage
  • Advantage plans require copay’s for doctor visits. Something you won’t find with most Medigap plans.
  • Many Advantage plans include prescription drug benefits. Sometimes the “package” covers the medications you need, sometimes not.
  • If you switch from original Medicare to an Advantage plan and you are not satisfied, you may disenroll during the first 12 months of your Special Enrollment Period (SEP) and return to original Medicare.


Medicare Advantage or Medicare Supplement

As I tell all my clients, it is your plan and your money. Whether you decide to participate in original Medicare and purchase a Medicare supplement plan or enroll in Medicare Advantage coverage.

One of the most common mistakes Medicare beneficiaries make is picking a plan based on the monthly premiums. Many Medicare Advantage plans have $0 premiums and what is better than “free”, right?

But zero premium doesn’t mean zero cost.


Ben and Maxine

Maxine has been a Medigap client since she turned age 65 and enrolled in Medicare. Her husband Ben is a few years older and had chosen a Medicare Advantage plan with a $0 premium. Ben is an avid tennis player and has enjoyed good health. Based on his past when it was time for him to enroll in Medicare he chose a Medicare Advantage plan.

Ben had endured knee pain for years and shortly after turning 65 his doctor told him it was time to consider knee replacement surgery. Surgery was scheduled for August and everything went as planned. The surgery, doctors and hospital was all covered under Ben’s Medicare Advantage plan. Most, but not all of his out of pocket expenses were in network. When it was all over Been owed over $3,000 to replace one knee.

The other knee also needed replacing but Ben decided to wait until the following January to have the second knee replaced.

At Maxine’s insistence, Ben called to ask my advice. Since he had pending surgery planned, a Medicare supplement plan was out of the question. The next best thing was to suggest Ben reschedule his surgery for December of that year rather than January. In doing so his out of pocket cost for knee #2 would be less than $500. Had he gone with his original plan he would have paid another $3,000 for the second knee operation.

Ben had the second surgery done and everything went well. A short while later after he was discharged from his doctors care Ben called and enrolled in a Medigap plan like the one Maxine has.

Is Medicare Advantage for you? They are great plans until you use them, and then you may not like them so well.