There are many layers to the federal Medicare program. Let us help you figure out where to begin. We'll break down Medicare into manageable pieces, so you know if you qualify for Medicare coverage, what coverage is available in your area, and how to get enrolled in a plan that fits your needs.

Medicare Advantage

Medicare Advantage (MA) plans are health plan options offered by private companies that contract with the federal government to coordinate Medicare Parts A and B. By joining one of these plans you are assigning your Medicare benefits over to the plan. This means that the insurance company will coordinate with Medicare for you. Many of these plans offer extra benefits that fill in the gaps of "original Medicare". In addition, most of these plans include Part D prescription drug coverage.

If the MA plan you choose offers Medicare prescription drug coverage (also known as an MA-PD plan), you must take the drug coverage your plan is offering. If you sign up for an MA plan that doesn't offer prescription drug coverage, you cannot sign up for a separate Part D plan.

Depending on which plan you pick, you may be limited to see doctors or go to hospitals that belong to the plan's network. There are three main types of MA Plans: Medicare Health Maintenance Organization (HMOs), Medicare Preferred Provider Organization (PPOs), and Medicare Private Fee-for-Service (PFFS) Plans.

Here is a brief description of how each type of MA plan works. With each of these plans, you will need to check with the individual plan offering for details and exceptions:

Types of MA Plans

  • Medicare HMO Plans: Except for emergencies, you generally must get your care from primary care doctors, specialists, or hospitals in the plan's network
  • Medicare PPO Plans: In most of these plans, you can visit any physician regardless of whether they are in or out of the plan's network of participating providers. However, you will pay less if you use primary care doctors, specialists, and hospitals in the plan's network.
  • Medicare PFFS Plans: If you join one of these plans, you can go to any primary care doctor, specialist, or hospital that accepts the terms of the plan's payment.

Cost

Each Medicare Advantage plan sets its own premium. In addition to the premium, you are responsible for paying the Medicare Part B premium, and any applicable deductibles, copays or coinsurance.

Medicare Advantage plans have a feature called 'maximum out-of-pocket', which sets a limit on the total dollars you are liable for in a given plan year. This number does not include premium payments, but provides you protections in the case of a catastrophic medical event.

Covered

Medicare Advantage plans pay for all services covered by Original Medicare. In addition, many MA plans offer supplemental coverage, which pays for services that are not covered under Original Medicare, such as hearing aids. There are also MA-PD plans that integrate medical and prescription drug coverage.