What are Medicare Advantage Plans (Part C)?

  • Medicare Advantage Plans (aka “REPLACEMENT Plans”) are another way for beneficiaries to get their Medicare part A & B benefits. It’s ALTERNATIVE coverage so instead of having Original Medicare Parts A & B as your primary insurance the Advantage plan becomes primary.
  • Advantage plans are NOT Medicare Supplement Plans (Medigap); They’re COMPLETELY DIFFERENT!
  • If you join an Advantage Plan, you give-up (replace) your Original Medicare Parts A & B. Medicare pays a private insurance company a fee every month for the company to administer your Part A & B benefits.
  • If you join an Advantage plan you may pay a low-premium or zero-premium, but the trade-off is that you will be RESTRICTED to limited networks of doctors/hospitals who must accept your plan
  • You will pay deductibles, copays, coinsurance up to the plan’s out-of-pocket-maximum
  • Additional rules apply such as using doctors/hospitals within the provider network
  • If you want to see a doctor/specialist/hospital outside of the network you may pay higher costs or not be covered at all
  • Many Advantage plans provide part D drug benefits (sometimes have higher out of pocket costs)
  • Be aware that doctors/hospitals can drop from the network at any time
  • Be aware that plan benefits and drug formularies can change at any time
  • Advantage plans may require getting prior authorization for many services and procedures
  • HMO plans are the most popular Advantage plan. They require you to have a PCP to coordinate your benefits and require referrals before seeing specialists. PPO plans allow you to see out-of-network doctors/hospitals but you will pay higher out-of-pocket costs.
  • Enrollment in an Advantage plan means that you are required to stay on that plan for one year (Jan-Dec)
  • You can only make changes to your plan during AEP or OEP unless you qualify for an SEP. Check to see if you qualify for a Special Enrollment Period by calling Medicare Sharks!

Considering a Medicare Advantage Plan to save money?

Considering that most retirees are on a fixed income, wouldn’t you want your healthcare plan to have stability with fixed costs with NO hidden fees or surprises?

Medicare Advantage plans often cover less expenses than Medigap — potentially resulting in more out-of-pocket expenses. With some Medicare Advantage Plans you may have big surpriseswith increased out-of-pocket payments when you see a specialist, need certain tests/scans, need extensive medical treatment like surgical procedures or hospital services and need cancer treatment. This makes it very tough to budget for your future unexpected healthcare costs.

However, Medicare Supplement Plans (Medigap) provide STABILITY with consistent monthly premiums so you know exactly what your future healthcare costs will be and you can budget accordingly. Medigap Plans help you AVOID getting surprised with expensive medical bills and stop you from paying every time you seek any type of medical treatment. Most Medigap plans have NO out-of-pocket costs.

Today you may be healthy but who knows what tomorrow brings?
The thing you can control is your quality of care while protecting your finances.

What’s the difference between Medicare Supplement Plans and Medicare Advantage Plans?

(see both charts below)

Medicare Supplement Plans vs. Most Medicare Advantage Plans
Concerns of Most Seniors: Medicare Supplement Medicare Advantage
Visit ANY doctor, specialist, hospital nationwide that accepts Medicare YES NO
Restrictive Networks of
Doctors & Hospitals
NO YES
Referrals Needed for Specialists NO YES
Expensive Out-of-Pocket Costs
(Copays, Deductibles, Coinsurance)
NO YES
High Maximum Out-of-Pocket Costs (approx. $6,700 – $10,000) NO YES
Health Plan Determines Approval for Tests, Services, & Procedures NO YES
Unwanted Plan Cancellation
(Not By Your Choice)
NO YES
Pre-Authorization Required for Some Tests, Services & Procedures NO YES
Potential Hidden Costs or Fees NO YES
Medicare Supplement (MEDIGAP) Advantage Plan (HMO/PPO)
Original Medicare A&B is your Primary coverage.
Medigap Plan is your Secondary coverage to pay your expenses.
REPLACE Original Medicare A&B with ALTERNATIVE coverage.
Primary coverage comes from the insurance company’s plan.
FREEDOM & CHOICE to get superior quality healthcare!
Visit ANY Medicare doctor, specialist, hospital in the USA including elite providers who accept Medicare
(NO restrictive networks)
Limited to providers in the plan’s network who must accept your specific plan (HMO/PPO). Typically, you cannot visit providers outside of your area’s network or you may pay additional costs or possibly have no coverage at all.
NO referrals to see specialists
Get immediate treatment which saves time and money!
Usually required to get referrals for specialists and may be required to use limited network specialists. This can delay your time before getting treatment and cost money for extra visits.
Coverage goes with you across the United States. No network restrictions. Some plans cover foreign travel emergency outside of the US. Usually have network restrictions limited to your plan’s local area. Some plans allow you to go out of network, but you’ll pay much higher/full costs. Most do not cover you outside of the US.
You can get a Medigap plan anytime you want once you have Medicare Part B Limited to certain times of the year when you can enroll or switch to another advantage plan
Affordable premiums to help limit various out of pocket costs
Plan F covers 100% ALL costs
Usually no premium but you will pay expensive copays, coinsurance, deductibles. Most max-out-of-pocket costs can average $6,700 – $10,000
Part D Prescription Drug Plans provide broader coverage and reduce your out of pocket costs Some plans include drug coverage, but your out-of-pocket costs tend to be much higher
SAVE MONEY! Eliminate or reduce out-of-pocket costs, copays and deductibles
Factor a fixed cost into your budget with NO surprises!
You are responsible to pay the plan’s copays, deductibles, out-of-pocket costs. Becomes expensive when you need quality healthcare as bills will add up and you can get surprises anytime!

When can I change my Medicare Advantage Plan (Part C)?

In most cases, you must keep your Medicare Advantage Plan for the full year Jan-Dec. During the Annual Enrollment Period (Oct 15 – Dec 7) you can make changes to your Medicare Advantage Plan and coverage will start Jan 1. There’s another opportunity to make changes to your Advantage Plan during the Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31). However, you may be entitled to a Special Enrollment Period (SEP) where you can change your plan mid-year. It’s always a smart idea to check with the Medicare Sharks licensed experts to see if changes to your Medicare Advantage Plan would benefit you!

I was told that Medicare Advantage Plans are “FREE” or “No-Premium/Low-Premium”?

Although, some Advantage Plans may have a zero-dollar monthly premium, there are many out-of-pocketcosts associated with Advantage Plans. Every Advantage Plan has a maximum-out-of-pocket amount, so it stands to reason that there are costs associated with Advantage Plans which you have to pay. Maximum-out-of-pocketcosts can range anywhere from $3,400 to $6,700 to $10,000 and each carrier’s plans are completely different. There are copays for doctors’ visits and even higher copays for specialists. There are deductibles for things like hospitalization. You’ll pay coinsurance for lab tests, bloodwork, X-rays, MRIs, CAT Scans, ambulance rides, chemo drug, and most procedures. By the time you end up paying for all these out-of-pocket costs, it may be more beneficial for you to pay a premium for a Medicare Supplement Plan (Medigap) and not have to pay anything else. Call the Medicare Sharks licensed experts who can help discuss your options so you can get the BEST COVERAGE and also SAVE MONEY!