Medicare Advantage Plans (Part C)
Once enrolled in Medicare you will want to choose supplemental insurance, either (Avenue 1) Medicare Supplement + Part D Rx Plan, or (Avenue 2) Medicare Advantage. This page explains the details of Medicare Advantage (Part C) plans.
Medicare Advantage plans, sometimes referred to as “Part C,” or “Not original Medicare,” are insurance plans for those age 65 or older and Medicare eligible (and even people under age 65 who are enrolled in Medicare). The plans differ from the Medicare Supplement + Part D plan coverage avenue in that the plan is “bundled coverage” The plan works in conjunction with Medicare to pay unmet costs at both the doctor’s office, hospital and pharmacy. One plan covers everything (“all in one”).
We Help Clients With These Medicare Advantage Plans (And More)
There are eight insurance companies offering PPO Medicare Advantage plans in our area; Aetna, Alignment Health, Blue Cross NC, CIGNA, Humana, Troy, UnitedHealthcare and Wellcare. We can offer information on all seven and help you compare.
A Quick History Lesson On How Medicare Advantage Plans Began Helps Explain How They Work
When those covered by a Medicare Supplement plan incur a medical service a “team” works to process and pay the claim…the provider first sends the claims to Medicare to be processed and paid, then Medicare sends the claim on to the Supplement insurer for their processing and payment. This claims system is amazing in its efficiency.
In the 1980’s the Centers for Medicare and Medicaid Services began to worry… soon the “baby boomers” would begin to turn 65 (currently 10,000 each day in the U.S.). Would the excellent claims system Medicare designed to process claims be able to handle the demand without problems?
CMS’s answer was the “Medicare Advantage” plan. If covered by a Medicare Advantage plan, Medicare’s claims system does not process your claims at all. Instead the insurer offering your Medicare Advantage plan takes over for Medicare, processing and paying Medicare Parts A and B claims, then their own claims according to your policy.
Medicare sort of offloads you to an insurance company, and pays that insurance company a fee to handle everything, to lighten the Medicare claims load nationwide.
Medicare Advantage Plans Look A Lot Like Health Insurance, “Copays for Everything”
If you have ever been covered by a copay-style health insurance plan, a Medicare Advantage plan will feel familiar. There is a copay you pay, or percentage of the cost you pay, for each incurred medical service. Medicare and the insurer pays the rest.
An Example:
Here’s a quick look at the plan benefits of a 2024 Medicare Advantage plan available in NC, to give you an idea. Ask today for a free quote and we will send you all the plan details.
Preventative Care: $0 copay
Primary Care Office Visit: $0 copay
Specialist Office Visit: $30 copay
Inpatient Hospital Care: $295 copay for days 1-5
Outpatient Hospital, Including Surgery: $195 or $295 copay
Diagnostic Tests: $20 copay
Lab Services: $0
Urgent Care: $40 copay
Emergency Room: $90 copay
Ambulance: $225 copay
Mental Health Office Visits: $25 copay
Prescriptions:
Preferred Generics: $0 copay
Non-Preferred Generics: $8 copay
Preferred Brand Name Rx: $47 copay
Non-Prefer. Brand Name Rx: $100 copay
Specialty Drugs: 33% of cost
Note, be sure to understand “Annual Out of Pocket Maximum”: The benefit detail we search for first when comparing Medicare Advantage coverage is the “Annual Out of Pocket Maximum.” This term means the most in out of pocket medical costs (copays or percentage of cost) you could pay before the insurer steps in and pays 100% for the remainder of the plan year. The example above carries an annual of out of pocket max. of $3,900 annually, one of lowest in the area. The average is between $4,500 and $8,500.
Medicare Advantage Plans Like to Offer “Extras”
When comparing Medicare Advantage plans, the covered medical benefits start to look similar (i.e., the same copays for the same services). Owing to this competitive market, insurers offering Medicare Advantage plans like to build in popular “extras;” discount programs and extra benefits that pay for services we use, to stand out as the best choice. Here are the extras we see most:
Wellness
Medicare Advantage plans offer access to a myriad of wellness programs.
The one benefit in this category everyone loves is either a reduced cost or free gym membership! (gyms, pools, Pilates studio, etc.)
Dental Benefits
Nearly all plans offer some dental coverage, benefits for dental exams and cleanings.
The dental benefits even offer coverage for dental services like cavities, root canal, crown, etc., paying up to $1,000 - $3,000 per year.
Vision Benefits
Most Medicare Advantage plans offer coverage for an eye exam after a copay.
The plans also coverage, paying for lenses after a copay, paying a set portion of the cost of frames and contacts, up to $300 per year.
Hearing Benefits
Many Medicare Advantage plans offer an annual hearing exam after you pay a copay.
In addition, insurers have built networks of providers to purchase hearing aids at a discounted or set, lower price per hearing aid.
Over the Counter Items
“OTC benefits” provide you with a preloaded debit card (that doubles as the ID card!).
You can utilize these monies for over the counter items you purchase at the pharmacy like toiletries, vitamins, OTC drugs, etc.
Meals After Surgery
After an inpatient hospital or skilled nursing stay your first aim once home is rest.
Insurers try to lighten the load by delivery nutritious meals to your home for a period of time after your surgery or skilled nursing stay.
Medical Transportation
Free medical transportation is part of “extras” packages.
The insurer will pay a local service to drive you to medically necessary appointments, usually up to a maximum number of one way trips per year (12-24).
“Give Back” Benefit
Some insurers advertise a “give back” benefit…money added to your Social Security benefit monthly ($50 to $150).
Sounds great, but beware…these plans usually feature the highest maximum out of pocket cost, $8-$10k+!
Advantages / Disadvantage of Choosing a Medicare Advantage Plan
When you begin to research Medicare Advantage plans they seem great. You may ask yourself, “Why would I choose anything else?” We think that a careful comparison of the two avenues; Medicare Supplement + Part D Rx or Medicare Advantage, specific to your needs, usually yields the best answer. Here are some key details of Medicare Advantage (Part C) to watch for in your comparisons.
Advantages:
Cost!
The monthly premium cost for Medicare Advantage plans are much less than for Medicare Supplements. Medicare Advantage insurance plans in North Carolina mostly range from $0 to $55 monthly.
Extras
Medicare Advantage plans lead the way in offering “extras” to entice you to choose their plan…benefits like free or reduced cost gym memberships, dental , hearing and vision coverage, discounts and monies to pay for OTC products and other medical services not covered by Medicare, free meals, and even transportation to medical visits.
Disadvantages:
More Out of Pocket Expenses
The trade off for a lower monthly premium cost is that you will share more in medical costs as you incur them. There will be copays and percentages of cost (“coinsurance”) owed by you for each medical service in the Medicare Advantage plan design.
The good news is that you do know when the out of pocket cost ends, as each plan lists the maximum out of pocket cost borne by the insured, usually in the $3,900-$8,000 annually range.
Compare this to Medicare Supplement Plan G that pays the medical costs left behind for you by Medicare Parts A and B with just one exception, the $226 Part B deductible.
Fewer In-Network Providers
Unlike Medicare Supplement plans that have to adopt every Medicare provider as their network, Medicare Advantage insurers can build their own list of in-network providers that are usually smaller than Medicare’s network.
Medicare Advantage plans can also determine if their network is PPO or HMO. PPO plan networks are best….you can visit any provider you want to, but to get the bet benefits you need to visit an in-network provider.
Caution!: With HMO plan networks you must visit an in-networ provider to receive benefits. If you go to and out of network, there is not benefit! (as if you have no coverage at all!)
Free Information Packet and Quotes
Complete the form below and we will send you clear, concise information about Medicare Advantage plans, along with quotes to consider from insurance companies. We will compare the plans’ benefits and costs, and recommend what looks best based on your details and preferences.
Note on Privacy: Keeping the information you share private is of the utmost importance to us. We do not share any information with third parties. A minimum of information (no contact info!) is shared with an insurance company to put together a detailed free quote and illustration for you.