What is Medicare Advantage?

How Medicare Advantage Works

A Medicare Advantage plan is a private Medicare insurance plan that you may join as an alternative to traditional Medicare. You must continue to stay enrolled in both Medicare Part A and B while enrolled in your Medicare Advantage plan as Medicare pays the Medicare Advantage company to take on your medical risk. This is how Medicare Advantage plans are funded. In many cases, Medicare Advantage plans have zero premium charges to the member but copays and deductibles will exist.

Each Advantage plan has its own summary of benefits which will tell you what your copays will be for various healthcare services. Your plan will offer all the same services as Original Medicare, such as doctor visits, surgeries, labwork and so on.

One nice thing about Medicare Advantage plans is that some of them offer benefits for routine dental, vision or hearing and gym memberships. When searching for Medicare Advantage plans with dental and vision, our experts here at My Medicare Network can help you compare those ancillary benefits between carriers.

Medicare Advantage Networks

In exchange for lower (and in many cases zero) premiums that Advantage plans offer, you agree to play by certain rules as most Medicare Advantage plans have HMO or PPO networks.

Medicare HMO networks generally require you to use only network providers, except in emergencies. You will need to select a primary care physician at application and that physician will coordinate a referral if you need to see a specialist. HMO’s are the most common form of Advantage plans available.

Medicare PPO networks allow you to see doctors outside the network but you’ll have substantially higher out-of-pocket spending to do so. It’s a personal decision which option is best for your situation, If you are deciding between Medicare Advantage and Medigap, you’ll want to consider some of the rules before you enroll.

Basic Medicare Advantage Rules

  • You must be enrolled in both Medicare Part A & B and live in the plan service area. Some people think they can drop Part B if they enroll in Medicare Advantage. This is not true! If you drop Part B while enrolled, you will immediately loose your Medicare Advantage plan coverage.
  • Medicare Advantage plans have one health question: Have you been diagnosed with End-Stage Renal Disease (kidney failure)?
  • Use network doctors and hospitals for the lowest out of pocket costs. Plans may have HMO or PPO networks. Most Medicare HMO plans do not cover anything out of network except emergencies. In PPO networks, seeing a provider outside the network will result in substantially higher spending.
  • Must get prior authorization for certain procedures, especially in Medicare Advantage HMO plans.
  • You must obtain a referral from your primary care physician before seeing a specialist on many HMO plans

You must direct your providers to bill your Medicare Advantage plan as people who enroll in Advantage plans for Medicare are agreeing, for the rest of the calendar year, to be covered by the plan instead of Original Medicare.

Medicare Advantage Enrollment Periods

Medicare Advantage plans have lock-in periods. You can enroll in one during Initial Enrollment Period when you first turn 65. After that, you may enroll or dis-enroll only during certain times of year. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year. You may only dis-enroll from an Advantage plan during specific times of the year.

The Annual Election Period in the fall is the most common time to change your Medicare Advantage plan. This period runs from October 15th – December 7th each fall. Changes made to your enrollment will take effect January 1.

If you decide to leave a Medicare Advantage plan and return back to Original Medicare, you must notify your Medicare Advantage plan carrier. Otherwise Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare.

This is a common billing nightmare that we see among people who enrolled on their own without the help of an agent.

It is in your interest to enroll in Medicare Advantage through a My Medicare Network insurance agent who can fully explain how the plan works. Enrolling without an agent means you’ll have to track down and fix any billing errors that occur.

Medicare Advantage Open Enrollment Period

Some people find themselves enrolled into a plan that their doctor doesn’t accept or that doesn’t include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan.

For this reason, Congress designed the Medicare Advantage Open Enrollment Period that runs from January 1st – March 31st each year. During this time, you can disenroll from any Medicare Advantage plan and return to Original Medicare and then you will be allowed to add a standalone Part D drug plan.

Unfortunately, this does not guarantee that you can return to the Medigap plan you had before. Unless this was your first time ever in a Medicare Advantage plan, then you will usually have to answer health questions and go through medical underwriting to get re-approved for Medigap. Consider this before dropping any Medigap plan to go to Medicare Advantage.

Your other option during the Medicare Advantage Open Enrollment Period is to change from your current Medicare Advantage plan to a different Medicare Advantage plan. Please be aware that you can only use this period once per calendar year.

Medigap vs Medicare Advantage

Without question, Original Medicare with a Medigap plan gives you very comprehensive coverage. The primary differences are that with Medigap plans, you can see any doctor that accepts Medicare anywhere in the nation.

Medigap plans also have more coverage in that Medicare pays 80% and your Medigap plan 20%, leaving you with little to no money out of pocket, plus you won’t have the repetitive copays that you will on a Part C plan.

Medigap plans also don’t change their benefits from year to year. This means they don’t require as much homework from you. You won’t have to annually review the upcoming benefit changes like you will on an Advantage plan.

However, Medigap plans do not include Part D coverage, so you will need to buy a separate Part D policy. They also do not offer any routine dental, vision or hearing while some Medicare Advantage plans may at least have a little bit of this. One other big difference is that Medigap plans come with higher monthly premium costs which typically increase either once or twice per year, every year that you own the policy. So costs will continue to rise every year, virtually guaranteed.

Do you pay Part B premium with Medicare Advantage?

Yes, you must first enroll in both Medicare Parts A and B before you are eligible to add on an Advantage plan. This is true even if the Advantage plan itself has a $0 premium. You will still pay your Part B premium to Medicare every month.

How are Medicare Advantage plans free?

Medicare Advantage plans are definitely not free but some plans have $0 premium. This means you pay no premium for the plan itself, but you will still pay the Part B premium to Medicare and you will pay deductibles, copays, and coinsurance as you use your benefits.

When you enroll in a Medicare Advantage plan, Medicare pays the Advantage plan insurance company a monthly fee to take on all of your medical risk. That is the reason why some plans can offer you a $0 premium as they are already getting paid by Medicare on your behalf.


People often ask us our opinion on which plan is the best Medicare Advantage plan. This varies based on a number of personal factors as what’s right for your friend or neighbor may not be right for you. Don’t risk making a mistake on something as critical as your health insurance and instead get help from an experienced agent who can explain your options in detail.

Contact My Medicare Network for help today at (440) 793-7745!

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