For those who are new to Medicare, you might not be aware that Medicare Parts A & B are not 100% comprehensive. Sure, they cover the majority of your healthcare needs, but there are certain services which are not covered that, if left unchecked, could cost you in the long run. There are many different types of Medicare supplement insurance designed to protect you and your life savings from these gaps. One such policy, called a Medicare Advantage Policy (or Medicare Part C), is designed to replace your federal Medicare benefits with a private health plan. This private plan provides seniors with basic Medicare benefits, additional coverage to protect you from Medicare gaps, and even offers you the option for ancillary benefits.
Federal Regulations for Medicare Advantage
When you sign up for Medicare Advantage, you are essentially transferring responsibility for your Medicare benefits from the federal government to a private insurance company. To protect consumers, federal laws prevent these private companies from offering you less coverage that what you are promised with Original Medicare (Medicare Parts A & B). Usually, though, Advantage plans come with benefits well beyond that of Original Medicare. And you, as a consumer, have the option to add more coverage if you can afford to.
Medicare Advantage Enrollment In Maryland
Right around 20% of seniors in Maryland are enrolled in a Medicare Advantage program right now. What are the other 80% doing? It’s hard to say for certain. They could be relying upon Medicare Parts A and B to help them with their costs. They could also still be on an employer plan. Or they may have specific medical needs which don’t fall into any of those categories.
|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
There are many factors which will help determine how affordable your coverage will be, as well as what sort of coverage you can hope to obtain. For obvious reasons, the healthier you are, the better. Additionally, seniors who enrolled in Medicare right when they turned 65 (Called the “Initial Enrollment Period”) will get more favorable rates than those who waited months or years. Below is a chart that shows estimates for plans near you:
Most Popular Medicare Advantage Plans in Maryland
Finding a good Medicare health plan near you is challenging, but not impossible. The first step is to educate yourself. Odds are that there are many options available in your area right now. Evaluating all of them and finding the best policy from the best provider is overwhelming for most seniors. That’s why we created Medigap.com – so that people like you can access our database and find the right insurance plan and the right provider quickly and easily.
Helpful Medicare Advantage Tips & Tricks
Doctor/Provider Network Restrictions
Depending on your plan, it is highly unlikely that your Medicare Advantage policy will be accepted as widely as Original Medicare. Advantage plans usually come with provider networks which, depending on the price of your policy, may come with a variety of choices – or be highly restrictive. Check with your current doctor to make sure that they are included in your Advantage policy’s provider network. Also, keep in mind that providers can change the rules and exclude doctors and facilities from their network at any time.
Where you generally need to get your care and services from for:
- HMO Plans – If you’re looking at an insurance plan with an HMO network, be prepared to deal with some restrictions. Your insurance provider will only honor claims from a network-approved doctor, hospital, or facility – with the exception of emergency care. But if the care you receive is not due to an emergency, you will likely have to pay 100% out of pocket.
- PPO Plans – PPO plans tend to cost more than HMO policies, but give you more flexibility with the care you receive. You will have network-approved doctors, hospitals, and facilities that you are encouraged to get care from first. If you can’t get network-approved care or if you want care from somewhere outside of your network, you will be covered – but it’ll cost more than what you would have to pay if you stayed in network.
- PFFS Plans – A Private Fee-For-Service plan falls somewhere in the middle of an HMO plan and a PPO plan. You get a wider variety of choices when it comes to receiving care, with slightly more affordability than a PPO. However, the care you get is either approved or declined on a case-by-case basis. This approval can change frequently, even if you’ve already received care from the same doctor or facility before. So it’s important to stay on top of that information and keep checking to make sure your care provider agrees to your insurance company payment terms before you receive care.
- Special Needs Plans – Any senior who has specific medical needs and requires specialized care to meet them could be eligible for a Special Needs Plan. They work similarly to HMOs in that if you receive out-of-network care which is not related to a medical emergency, you will have to pay 100% out-of-pocket. Non-emergency out-of-network exceptions may be made if you can prove that you have a legitimate medical need which cannot be met otherwise.
Finding a doctor who accepts your Medicare Advantage plan:
- HMO Plans – Medicare Advantage HMOs work the same way you would expect from an HMO policy offered by a private company. You still have the same non-emergency care restrictions. The only difference is that with a Medicare Advantage HMO plan, the federal government is helping to pay for a portion of your premiums.
- PPO plans – Some Medicare Advantage plans come with a PPO network instead of an HMO network. As you’ve already read so far, PPO networks give you a much larger pool of doctors and facilities to choose from. You don’t have to stay in network, but if you do, you will save money. If you do decide to go out of network, you’ll still have a decent portion of your costs covered due to the fact that your insurance is associated with Medicare.
- PFFS Plans – Private Fee-for-Service plans on Medicare Advantage don’t exactly have the same benefits as Original Medicare. Despite the Medicare moniker, you’ll have to call ahead first and make sure that your chosen doctor or facility a) accepts your particular MA plan, and b) accepts your insurance company’s payment terms for the care you need. There are exceptions for emergency care with PFFS plans as well.
- Special Needs Plans – Are you suffering from a chronic condition like ESRD and need specific medical care? There are Medicare Advantage SNPs for that. You’ll likely have a limited network of doctors and facilities to choose from, not unlike that of an HMO. This helps keep costs affordable while granting you access to those who can give you the specific care you need. Furthermore, there are exceptions for emergency care. To get a non-emergency care exemption, you’ll have to negotiate with your insurance company or pay out-of-pocket.
Drug, Vision and Dental Coverage
Most Medicare supplements, such as a Medigap policy, don’t leave room for extra coverage options which you may need. Some of these options include prescription drugs, dental care, and vision. But with a Medicare Advantage policy, you are free to combine all of these services together, or pick and choose which ones you would like to add. Advantage plans which include Medicare Part D prescription drug coverage are also known as MAPD plans.
- Neither Original Medicare nor Medicare supplement insurance offers vision coverage; but Medicare Advantage does. Vision coverage is not available in all areas, and not all vision plans are the same. You’ll have to communicate with your insurance provider if you want details about total costs and providers which are available to you.
- There is something similar going on with Medicare Advantage and dental coverage. It may not be available everywhere, but it is a popular piece of optional coverage which most MA plans offer. It might raise your premiums and overall health care costs, but may seniors find it affordable and don’t find the dental and orthodontic networks too restrictive.
Enrollment Options & Best Time To Enroll
The best time to enroll in a Medicare Advantage plan is when you are newly enrolled in Medicare, 65 years of age, and in good health. There will be fewer obstacles for you to overcome in order to get approved for coverage. Remember though that because you are applying to a private company, they are more likely to ask questions about your health and deny you over pre-existing conditions, such as ESRD (End Stage Renal Disease). However, you have options. Your state department of insurance will tell you more. You may also visit our Medicare Advantage Enrollment Page for more info.
- Initial Enrollment Period: The enrollment period during your first 6 months of being enrolled in Medicare.
- 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): Circumstances which happen outside of the AEP window, such as employer coverage loss or moving out of state, which may require you to find new coverage immediately.
What Medicare Advantage Plan Is Best For Me?
Choosing the right Medicare Advantage plan can be a process. These plans are managed by private insurance companies with a bottom-line, profit-driven focus. This may make them more financially stable, but you’ll have to keep your eyes peeled for the companies that aren’t. You’ll also have to keep an eye out for those insurance providers who work hard on their customer service satisfaction.
As if shopping around weren’t hard enough, you’ll also have to make a decision quickly! The enrollment period window is quite narrow. But we’ll be more than happy to help you make a good decision in the time you have left. Feel free to get in touch with one of our operators so we can get you in touch with the Medicare Advantage plan that best suits your needs.