Medicare Advantage What You Need To Know

Medicare Advantage What You Need To Know

If you have Medicare or you are close to getting it, you will be hearing a lot about Medicare Advantage plans or also know as MA Plans. For some people, these plans are a great option, but for others, they are a nightmare. Continue reading this article “Medicare Advantage What You Need To Know” to learn everything you need to know.

What is a Medicare Advantage Plan?

Medicare Advantage Plans are offered by private insurance companies that contract with Medicare to provide Part A and Part B benefits. If you choose an Advantage plan, Medicare will pay that insurance company a fee for them to take care of your healthcare services.  

These plans have to follow Medicare rules and regulations and they have to offer at least the basic coverage that is offered by Medicare Part A & B. Most people don’t have a Medicare Part A premium so you don’t have to worry about that but you have to continue paying your Part B premium even if you switch to an Advantage plan.

There are several different Advantage plans

  • Health Maintenance Organization (HMO)  
  • Preferred Provider Organization (PPO)
  • Private Fee-for-Service (PFFS)
  • Special Needs Plans (SNPs)

Other less common types of Medicare Advantage Plans that may be available include HMO Point of Service (HMO-POS) Plans and a Medicare Medical Savings Account (MSA) Plan.

Most people who are interested in an Advantage plan usually choose an HMO. For people who have diabetes are usually on Special Needs Plans for that particular condition.

Let’s look at an HMO Plan because these are the most common

HMO stands for Health Maintenance Organization. These are the plans you see advertised as having a $0 premium. Most have prescription drug coverage included and some even are offering to give you back your Medicare Part B monthly premium if you sign up with them.

HMO Requirements

If you sign up for an HMO Advantage plan you will have to follow rules set by that plan.

You can NOT do whatever you want or go wherever you like as you can with Original Medicare. If you don’t follow these rules you might have to pay all your medical bills out of pocket.

HMO plans require you to use in-network providers and facilities. That means you have to use specific doctors and facilities that a contract with the plan you are interested in. If you don’t use in-network providers or facilities, you might have to pay more or ALL of that medical bill.

Your Doctor

When you first sign up for a Medicare Advantage plan, you will have to choose a Primary Care Provider (PCP). This will be your doctor whom you go to on a regular base and they will coordinate all your healthcare.

You can NOT just go to any doctor as you can with Original Medicare. If you don’t like your Primary Care Provider, you have to find another doctor who accepts your plan. Doctors decide every year which plans they will accept, if your doctor decides not to keep your HMO plan, you will have to find a new doctor.

If your plan decides not to keep your doctor in their network, you will have to find a new doctor as well. You will be informed of any network changes by your plan well ahead of the change and they will tell what options you have.

Your Specialists

Sometimes we need to go to a Cardiologist, Dermatologist, Eye doctor or any other doctors who specialize in something you need help with. You can NOT just call them and make an appointment as you can with Original Medicare.

Your Primary Care Doctor has to give you permission (called a referral) to go to that Specialist and he has to provide proof to the HMO plan why that is necessary. If you sign up for an HMO plan, get used to the term “Pre-authorization“. That term is used when you need to get permission from an Advantage plan to go see certain doctors or receive certain treatments.

Your Hospitals

Not all hospitals will be in your plan network. You have to make sure that your Primary Care Provider has admittance privileges at the hospitals you like.

If you have a medical emergency, of course, go to the nearest ER but if it’s not an emergency and you go to a hospital that is not in your network you might have to pay the whole bill.


Most Advantage plans have co-payments when you use services.

To give you an example of the types of co-pays you may find, here are some details of in-network services from a popular Advantage Plan in Florida (34655 zip code):

  • Ambulance – $300
  • Hospital stay – $175 per day
  • Diabetes supplies – up to 20% co-pay
  • Diagnostic radiology – up to $125 co-pay
  • Lab Services – up to $100 co-pay
  • Outpatient x-rays – up to $100 co-pay
  • Therapeutic radiology –  20% co-pay
  • Renal dialysis – 20% of the cost


If you have an Advantage plan and you get CANCER, you will have to pay 20% of the cost of your chemotherapy. Chemotherapy with Original Medicare is not covered by prescription drug plans (Part D), it is actually covered by Medicare Part B which has a 20% copayment.

Advantage plans DO NOT offer anything extra then what they are required to offer as set by Medicare rules for Chemotherapy. If your plan only allows for a certain amount of treatment but your doctor prescribes more, you might be required to pay all of the cost for those treatments which were not pre-authorized.

Maximum Out-Of-Pocket

Most Advantage plans have a Maximum Out-Of-Pocket which protect you from catastrophic medical expenses. Most plans have a $3,000 to $6,000 per year Maximum Out-Of-Pocket limit. This does not include your Prescription drug costs, those are separate.

When can you join?

If you are Medicare-eligible or you already have Part A & B you can sign up for a Medicare Advantage plan during specific times of the year.

If you are first time eligible for Medicare, you have what’s called your Initial Enrollment Period. During this time you can join an Advantage Plan with prescription drug coverage. You can keep original Medicare and buy a Medicare Supplement Plan (Medigap) and you can also buy a Part D prescription drug plan along with your Medigap policy.

If you are already on Medicare and would like to switch plans, you can do so yearly from Oct 15 to Dec 7, this is the Annual Enrollment Period. Here you can switch Advantage plans or join a Part D plan if you want to go back to original medicare. You can also switch between different Part D plans if you already have one but want a better one.

Jan 1st to March 31 is called the Medicare Advantage Open Enrollment. You can make changes again, this time if you are not happening with the decision you made during the annual enrolment period. Again, you can switch advantage plans or go back to original medicare.

Special Enrollment Period (SEP) can be used throughout the year if you, for example, move or your plan leave the service area. Many reasons fall under the category, and you should always ask if one applies to you.

If you have any questions about Medicare, I’m here to help you. You can call me directly (813) 842-1421 or send me an Email

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