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What to Look for in a Medicare Advantage Plan

Starting in 2019, Medicare Advantage (MA) Open Enrollment runs from January 1 through March 31. If you already have a Medicare Advantage plan, you can make one change during this three-month window: Either switch back to Original Medicare or change to a new MA plan. In this post, we describe what to look for in a Medicare Advantage plan.

If you choose to return to Original Medicare, you may also choose a Part D drug plan. However, you cannot sign up for a new Part D plan if you started the new year enrolled in Original Medicare. That change must occur during the Annual Enrollment Period that begins October 15.

Why Choose Medicare Advantage?

According to the Kaiser Foundation, Medicare Advantage enrollment rose steadily over the past 15 years, doubling since 2008. Today, over one-third of all Medicare beneficiaries have an MA plan.

One reason for the growing popularity is the fact that premiums keep dropping. In 2019, the average monthly premium is around $28, a 6 percent reduction over 2018 prices. You can also find plans with zero premium – around half of Medicare Advantage enrollees don’t pay a monthly MA premium. But even if they do have a premium, many MA plans are cheaper than what enrollees would pay for Original Medicare plus a Medigap plan.

MA beneficiaries also like the additional services most plans offer. Prescription drug coverage is fairly common, but many plans also include vision, dental, and hearing benefits. You may also find an MA plan with long- or short-term care options, such as adult daycare and in-home support.

What to Look for in a Medicare Advantage Plan

Not all plans are created equal. You need to look at the plan’s network, out-of-pocket costs (not just the premium), additional benefits, and more. The following sections discuss what to look for in a Medicare Advantage plan.

Medicare Advantage Plan

Are Your Providers in the Plan’s Network?

Medicare Advantage plans include a network of covered providers. In addition to your primary care doctor, the plan network should include clinics, labs, hospitals, and specialists. If the plan includes prescription drug coverage, it likely also has a pharmacy network.

HMOs typically do not cover out-of-network services. If you choose a PPO plan, it may cover services received by an out-of-network provider but at a higher cost to you. For example, if your doctor is not part of the plan network, your copay may be $50 instead of $20.

If the plan’s network does not include your doctor, you need to either choose a new doctor or a different plan. Even if your doctor accepts Medicare, he or she doesn’t necessarily accept Medicare Advantage, so be sure to check.

Does the Plan Cover Your Prescriptions?

If the plan includes prescription drug coverage, make sure it accepts your prescriptions. In addition, you want to know the costs, since these can vary greatly by each plan.

The plan’s formulary may include tiers or steps. If your prescription is on an upper tier, the plan may only cover it if a similar drug on a lower tier is deemed ineffective by your doctor.

Finally, look what happens with your prescriptions if you enter the donut hole. In 2019, you enter the donut hole once you and your plan spend a combined total of $3,820. While in the coverage gap, you pay 25 percent of your plan’s cost for name brand drugs and 37 percent of generic drugs.

Once your out-of-pocket spending hits $5,100 for the year, you leave the donut hole and enter catastrophic coverage.

What Are the Plan’s Costs?

Many beneficiaries make the mistake of looking only at the monthly premium when it comes to MA plan costs. Often, low premiums (or no premiums) hide a high yearly deductible or copays. Review all of the out-of-pocket costs for the plans in your area to see how much the plan will truly cost you.

what to look for in a medicare advantage plan

What Are the Maximum Out-of-Pocket Costs?

One advantage (no pun intended) of an MA plan is that each one has a yearly maximum for out-of-pocket costs (Original Medicare does not have yearly out-of-pocket maximums). Medicare sets the out-of-pocket limit every year; it is $6,700 in 2019. However, not all MA plans set their maximum that high. In fact, only around one-third do. The others set their yearly maximums lower – sometimes cutting it in half. Double check the plan to see what their yearly out-of-pocket max is.

Does the Plan Include Additional Benefits?

Receiving additional benefits may be the most popular reason for choosing an MA plan over Original Medicare plus Medigap. Each plan determines its own benefits, although all must offer the same services covered by Original Medicare.

Most plans include prescription drug coverage (although not all, so check!). Other popular offerings include dental, vision, and hearing benefits. When you review plans on the Medicare plan finder, if you see a small circle that contains a D (for dental) or V (for vision), that means it offers that benefit. Pricing varies according to plan and provider.

Check each plan for particulars regarding covered services.

What Is the Medicare Advantage Plan’s Quality and Performance Rating?

Medicare provides quality and performance ratings for every Medicare Advantage plan. You can even sort your results by star ratings using Medicare’s plan comparison tool.

Does the Plan Cover You While Traveling?

One reason many beneficiaries choose Original Medicare and a Medigap plan is that they’re covered anywhere in the United States that accepts Medicare. Most MA plans only cover emergency care when you’re traveling and out of network. If you summer in one state and winter in another, this can present difficulties. Some plans offer a national network, but you won’t know unless you talk to the plan provider – does not provide this information on its site.

Talk to Medicare Solutions

Sorting through your Medicare Advantage plan options can be confusing and time-consuming. The licensed agents at Medicare Solutions can help you find the ideal plan for your needs and budget. Just call us toll-free at 855-350-8101 to get started.

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