Medicare Advantage (also known as Medicare Part C) is a type of Medicare supplement insurance policy which aims to protect you from the potentially expensive coverage gaps in Original Medicare. However, it does more than most supplements in that it effectively replaces your federal Medicare benefits with a more comprehensive policy. It is a private form of health insurance issued and underwritten by a private insurance company. This differs from other supplemental insurance in that you will only be managing the one policy, instead of your federal Medicare benefits alongside a separate supplement.
Federal Regulations for Medicare Advantage
To protect seniors like you from fraud, federal laws closely regulate the type of coverage which companies are allowed to offer you with a Medicare Advantage plan. Your policy must offer at least the same amount of coverage as Traditional Medicare (Parts A and B). They cannot legally offer you anything less. The good news is that most companies are happy to offer as good or better coverage – but the more coverage you add to your policy, the more expensive it will become.
Medicare Advantage Enrollment In Massachusetts
Massachusetts seniors are flocking to Medicare Advantage programs in growing numbers. The most recent data shows that over 21% of retirees are managing their healthcare needs with a Medicare Part C insurance policy. So what are the other 79% doing? It’s hard to say, but they might be using an old employer health plan, Original Medicare, or other supplemental coverage.
|Plan Type||Enrollment Percentage|
|Local PPO Plans||13%|
|Special Needs Plans||11%|
|Regional PPO Plans||9%|
|Private Fee-For-Service Plans||5%|
|Other (Cost Plans, MSA’s, etc.)||3%|
Plan Coverage & Cost
Like most other insurance policies, there are a few basic things which will influence your overall rate: location, age, current health status, and so on. If you take a look at the chart below, you can get an idea of what you might expect to pay:
Most Popular Medicare Advantage Plans in Massachusetts
Here on Medigap.com, we rank our Medicare plans so that you know which ones are right for you. And we make our ranking simple to understand with a trusted 5-star rating system. The more stars a company has, the more you can rely on them to manage your chronic conditions, tests, screenings, and provide quality customer service when it comes to your health. Our rankings also take a company’s financial stability and affordability into account.
Helpful Medicare Advantage Tips & Tricks
Doctor/Provider Network Restrictions
For the most part, Medicare is almost universally accepted no matter what doctor or hospital you go to. Medicare Advantage, on the other hand, is not. Depending on your plan (and how much you are willing to pay for your policy), you may be forced to receive your medical care within a very restrictive network. Likewise, it is not uncommon for a doctor who is currently in your network to suddenly no longer be accessible to you. These are important details to keep in mind when considering a Medicare Advantage policy.
Where you generally need to get your care and services from for:
- HMO Plans – A Health Management Organization plan is one where your network of doctors, hospitals, and other sources of medical care is highly restricted in order to keep costs low. Going out of network usually means paying out of pocket for your healthcare treatment. But you can visit any hospital or emergency care facility if you are in need of urgent, emergency care. There are also Point-of-Service exceptions.
- PPO Plans – Preferred Provider Organizations allow you to visit almost any doctor, hospital, or facility that you choose. But there is a network of providers your insurance company would prefer you use first before going out of network. They reward you with staying in-network by offering better prices and paying out more on claims from preferred providers. But your out-of-pocket costs will still be shared between you and your insurance company, even from non-preferred providers.
- PFFS Plans – Private Fee for Service plans are flexible, but somewhat high-maintenance. You can see almost any healthcare provider or use any facility you wish, as long as they agree to the payment terms of your insurance company. But unlike with a PPO, not all available providers will accept your PFFS insurance and may refuse to treat you. This is true even if they have agreed to treat you in the past with the same insurance policy. Make sure to call ahead and confirm things so that you don’t end up paying higher costs due to an unforeseen change in payment terms.
- Special Needs Plans – Elderly individuals with specific chronic diseases (like ESRD) or who are in hospice care are usually eligible for Special Needs Plans. These plans restrict your hospitals, doctors, and facilities in order to keep costs low, just like an HMO. But the healthcare providers in the network are specifically chosen based on your unique (and usually expensive) healthcare needs. Also, like an HMO, there are emergency care exceptions for out of network hospitals. There are also exceptions to get treatment from out of network specialists if you negotiate with your insurance company first.
Finding a doctor who accepts your Medicare Advantage plan
- HMO Plans – HMO Medicare Advantage plans work the same way they would with a private health insurance plan. Unfortunately, you will still be restricted to a smaller network of doctors and facilities. But because your plan is Medicare Advantage, it will cost less than a traditional private health insurance plan. You will also have the same emergency care and PoS exceptions.
- PPO Plans – PPO Medicare Advantage plans are just like private health insurance plans that rely on a PPO network of doctors and hospitals. You can see whatever provider you want, whenever you want, but you’ll be paying more for out of network providers. And the fact that it’s a Medicare Advantage plan means that your costs should be lower than a typical PPO private health insurance plan.
- PFFS Plans – Medicare Advantage PFFS plans rely on payment term agreements between your healthcare providers and your insurance provider before you can get treatment. You’ll need to be just as proactive and thorough about making sure your providers and your insurance company are on the same page as you would with a non-Medicare Advantage PFFS plan.
- Special Needs Plans – Special Needs Plans on Medicare Advantage are the same as they would be if you were using a private health insurance policy which relies on a Special Needs network. But, like all other Medicare Advantage plans, your plan is less expensive thanks to government subsidies.
If you already have doctors, hospitals, and facilities you want to continue getting care from, you should use the Medicare.gov Physician Search Tool to make sure that you choose a plan with a network that includes them.
Drug, Vision and Dental Coverage
The inconvenience of the restricted provider networks is balanced out by the convenience of additional coverage options which an Advantage policy can provide. MAPD plans (Advantage plans which also include Medicare Part D prescription drug benefits) are very popular. Additionally, you can add dental or vision care coverage to virtually any Advantage plan you sign up for. For many seniors, it’s easier to manage their health care needs when everything is covered under a single, solitary policy. However, the costs of all that coverage can add up.
- Vision coverage isn’t usually included on a private health insurance plan. But Medicare Advantage plans are an exception to this rule. If your Medicare Advantage plan gives you the option to include vision coverage, talk to your insurance agent about the specific terms. You may have a restricted network of eye doctors and lens crafting facilities that you have to patronize.
- Neglecting your dental health can create problems in other parts of your body, too. Yet, strangely, very few private health insurance plans include dental coverage. Thankfully for seniors, most Medicare Advantage plans do include a dental option. But, like vision coverage, your network may be restricted to plan-approved dentists and orthodontists. Be sure you know what sort of dental network you have before you start making appointments and getting care.
Enrollment Options & Best Time To Enroll
Enrolling in a Medicare Advantage policy can and should be done right around the same time that you enroll in Original Medicare. Once you start receiving benefits, and the closer to 65 years of age that you are, the easier it will be to get your policy approved by your provider of choice. Keep in mind though that serious pre-existing conditions, such as End Stage Renal Disease, could make it difficult to find a provider who is willing to accept you. For more options, feel free to contact your state department of insurance. Also, take a look at our Medicare Advantage Enrollment Options page to learn more.
- Initial Enrollment Period: 6-month timeframe when you first enroll in Medicare to purchase a Medicare Advantage plan.
- Annual Enrollment Period (AEP): This timeframe runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
- Special Enrollment Period (SEP): During special circumstances, you may be eligible to purchase/change a plan outside of the Annual Enrollment Period. Things such as moving out of the plans’ service area, losing group health or employer coverage, a company no longer offering plans in the area, etc. are all events that could trigger a SEP.
What Medicare Advantage Plan Is Best For Me?
It’s nearly impossible to know what your medical needs will be down the road. But you should still try your best to make an educated guess. The more accurately you anticipate your own future needs, the best value you will get out of your Medicare Advantage plan. The more demanding your needs are, the more important it is to find a financially stable healthcare provider with good customer service and care management expertise.
You’ll start comparing quotes between your top choice companies at some point. And we want to be there for you when that time comes. Choosing a Medicare Advantage provider is complicated due to the nature of restrictive enrollment periods (among other things). But our Medicare Advantage experts are standing by, waiting for your call.