Guide to Comparing Medicare Advantage Plans
- This step-by-step guide can help you compare Medicare Advantage (Part C) plans to find the right type of plan for you. Learn more about plan benefits, costs, coverage limitations and more.
There are thousands of Medicare Advantage plans (also known as Medicare Part C) sold by dozens of different carriers in the U.S. How do you compare plans and decide which plan truly is best for you?
This guide outlines the major cost, coverage and benefits considerations you should consider as you compare Medicare Advantage plans.
Decide Which Benefits Are Important to You
Many Medicare Advantage plans distinguish themselves from Original Medicare (Medicare Part A and Part B) by offering some additional benefits that Original Medicare doesn’t cover.
Medicare Advantage plans are required to provide all of the same benefits as Original Medicare, and most plans also prescription drug coverage. Some of the other popular extra benefits that some plans may offer include:
- Dental care
- Vision care
- Eyeglasses and contacts
- Hearing aids
- Over-the-counter (OTC) medical supplies
- Home meal delivery
- Non-emergency medical transportation, such as trips to your doctor’s office
- Membership to fitness clubs or groups such as SilverSneakers or Silver&Fit
Decide what benefits are most important to you. If a special feature such as dental coverage is important to you, look for plans that cover the dental services you need and make sure your dentist accepts those plans.
Compare How Different Plans Could Affect Your Budget
Depending on the plans available where you live, you may be able to find Medicare Advantage plans that feature $0 monthly premiums. Conversely, you might find plans with a higher monthly premium but lower or $0 deductibles, copayments or coinsurance.
You can also consider what type of plans are available. HMO plans (which are outlined below) often offer monthly premiums that are lower than PPO plans or PFFS plans, but they typically have more provider network restrictions.
Find Out If Your Doctor Is Part of the Plan Network
Depending on where you live, there may be one or several types of Medicare Advantage plans available for you to enroll. Each category of plan will have its own restrictions about how and where the benefits may be used.
- Health Maintenance Organization (HMO) plans – HMO plans usually come with a specified provider network. If you receive health care services outside of your plan network, they won’t be covered except in the case of emergency care.
- Preferred Provider Organization (PPO) plans – PPO plans will pay for services if you go outside of the provider network, but they will be less expensive if you receive those same services from a doctor or provider who is part of your plan network. PPO premium costs are typically higher than HMO plan premiums because of the added network flexibility.
- Private Fee-for-Service (PFFS) plans – A PFFS plan is typically more flexible than HMO plans and PPO plans, because you aren’t required to select a primary care physician and you can usually visit any doctor or provider who accepts your plan terms, without any network restrictions.
- Special Needs Plans (SNPs) – A Medicare SNP can provide coverage that is specifically tailored for people with certain chronic medical conditions, people with low incomes or people who live in care facilities.
Medicare Advantage plans typically feature networks of participating doctors, pharmacies and other health care providers. Make a list of your current providers and facilities that you wish to keep using and find out if they’re included in the plan networks.
Ask If the Plan Covers Your Prescriptions
When you compare Medicare Advantage plans that include prescription drug coverage (called MAPD plans), find out which plans cover your drugs and how much they cost.
You can find this information in the plan’s formulary, which is the list of drugs covered by the plan and includes the pricing tier for each covered medication. You can also ask a licensed insurance agent or a representative from the plan carrier whether or not your prescriptions are covered by the plan.
Consider the Medicare Star Rating
Each year, the Centers for Medicare and Medicaid Services (CMS) rates all Medicare Advantage plans on a 5-star scale based on various quality measures such as customer satisfaction and health outcomes. The Star Ratings are updated each year, and plan ratings can change from one year to the next.
When you compare Medicare Advantage plans, you can review their Medicare Star Ratings to get a better idea whether one plan is higher quality than another.
Know When You Can Enroll
It’s important to know when you can enroll in or change Medicare Advantage plans, because there are limited times during the year during which you can sign up for a plan.
The first is during your initial enrollment period (IEP), which begins three months before your 65th birthday, includes the month of your birthday and continues for three additional months for a total of seven months.
The second opportunity comes during the annual enrollment period (AEP), which is often referred to as the fall Medicare Open Enrollment Period. This enrollment period runs from October 15 to December 7 each year, and it is typically the only time of the year during which you can enroll, disenroll or switch Medicare Advantage plans or Medicare Part D prescription drug plans.
There are certain circumstances that may make you eligible for a special enrollment period (SEP), which can be granted at any time throughout the year.
What Are the Advantages of Medicare Advantage Plans?
Nearly 4 out of every 10 Medicare beneficiaries nationwide are enrolled in a Medicare Advantage plan, and their reasons for doing so are varied.
A Medicare Advantage plan can package all of your health care, including all of your Original Medicare benefits and any additional benefits offered by the plan. As mentioned above, some of these extra benefits may include things like dental, vision and prescription drug coverage, which you’d be able to use under one easy plan with just one insurance card. No more keeping track of multiple policies for different areas of coverage.
Out-of-Pocket Spending Limits
Original Medicare does not include an annual out-of-pocket limit, which can leave beneficiaries accumulating medical expenses throughout the year, with no end in sight. Medicare Advantage plans are required by law to include a maximum out-of-pocket spending limit for covered plan costs, which in 2021 can be no more than $7,550.
Beneficiaries of Medicare Advantage HMO plans and PPO plans typically choose a primary care physician who coordinates their health care along with other providers who are part of the plan network, often providing referrals for specialized care. Studies have shown this type of coordination of health care services can produce better health results.
Special Needs Plans (SNPs) are specially designed types of Medicare Advantage plans tailored to meet the needs of people who have specific health conditions or circumstances, offering a more customized approach to care.
What Are the Disadvantages of Medicare Advantage Plans?
The provider network limitations of an HMO Medicare Advantage plan might not be a good fit if you especially want to have a plan with more flexibility.
If you travel domestically frequently, if you use a lot of specialized care from providers who aren’t part of the plan network or if you have a primary care physician who you don’t want to give up because they’re not in the plan network, then you may want to consider a different Medicare Advantage plan or a different type of Medicare coverage altogether, such as staying with Original Medicare.
Connect With a Licensed Insurance Agent
Gathering info for all plans available in your market is a tall order, so it can be helpful to work with a licensed insurance agent who can compile your options and help you sort through them one by one to analyze costs and coverage.
Plus, an agent will be able to answer the many questions you’re sure to have along the way and help get you properly enrolled once you decide what coverage is best for you.
Here’s what you’ll want to discuss with your agent:
- Extra benefits that are necessary for you.
- Costs, and how those costs are distributed between upfront premiums and cost-sharing during plan use.
- Plan type.
- Participating providers you’d like to keep seeing.
- Drugs that you take.
- Quality ratings.
You may only purchase a Medicare Advantage plan that is sold in your area. Plan availability may be based on your county, zip code, state or region.