The Evidence on Medicare Advantage Plans, Without the Hype

Key takeaways

• Also called: Part C
• Must cover: everything Original Medicare covers, except hospice, which Original Medicare still pays for
• Most useful single change: Check that your doctors, hospitals and pharmacies are in the plan's network.
• Commonest mistake: Choosing a plan only for extra benefits such as gym memberships.
• See a doctor if any of the signs under "When to speak to a doctor" below apply to you.

What it is

Medicare-approved plans from private companies, also called Part C, that replace Original Medicare as the way you get your Part A and Part B benefits. It sits within Medicare And Medicaid. Below are the published figures, in one place.

The numbers, in one place

What helps

These are the changes with the clearest evidence behind them. Start wherever it is easiest to start.

• Check that your doctors, hospitals and pharmacies are in the plan's network
• Look up the plan's out-of-pocket maximum and drug list, not just the premium
• Read the Annual Notice of Change each fall to see what is changing next year
• Use the Medicare Plan Finder on Medicare.gov to compare plans side by side

What to avoid

The common mistakes, including the ones that sound sensible.

• Choosing a plan only for extra benefits such as gym memberships
• Assuming you can switch back to Original Medicare and buy Medigap later on the same terms
• Joining a plan without checking whether you need prior approval for services you use

In depth

A Medicare Advantage plan is a private insurance plan that Medicare pays a set amount each month to manage your care. Once you join, the plan rather than Original Medicare handles your hospital and medical claims. You still have Medicare and still pay your Part B premium, but you use the plan's card, follow its rules and pay its copays. Most plans bundle hospital, medical and drug coverage into a single package.

The trade-off at the heart of Medicare Advantage is cost protection and convenience in exchange for some loss of choice. Plans must cap what you pay each year for covered services, which Original Medicare does not, and many charge little or no premium beyond Part B. In return, they often limit you to a network of providers, require referrals to see specialists, and ask for prior authorization before certain tests, procedures or hospital stays.

Plans differ widely, even within one county. Two plans from the same company can have different networks, drug lists and copays. Plan types include health maintenance organizations (HMOs), preferred provider organizations (PPOs), private fee-for-service plans and Special Needs Plans for people with particular conditions or with both Medicare and Medicaid. Because plans can change their benefits, costs and networks every year, the plan that suited you last year may not suit you now.

Signs and symptoms

• A letter saying a service needs prior authorization before the plan will pay
• Higher bills, or no coverage, after seeing a provider outside the plan's network
• An Annual Notice of Change arriving each fall describing next year's costs and benefits
• A notice that your doctor or hospital is leaving the plan's network
• Copays at each visit instead of a percentage coinsurance

Causes and risk factors

• Whether your current doctors and hospitals are in the plan's network
• How often you need specialist care, tests or hospital stays
• The prescriptions you take and where they fall on the plan's drug list
• Whether you spend months of the year away from home
• Your appetite for risk if you develop a serious illness later
• Whether you have a chronic condition or both Medicare and Medicaid, which may qualify you for a Special Needs Plan

How it is checked

Judging whether a plan fits you means looking past the premium. The Medicare Plan Finder lets you enter your drugs and pharmacies and compare total estimated yearly costs, and each plan's Evidence of Coverage document spells out the rules in detail. Check the out-of-pocket maximum, the copays for hospital stays and specialists, and which services need prior authorization. Medicare also publishes star ratings from 1 to 5 that reflect quality and member experience.

To check a network, do not rely only on an online directory. Call your important providers and ask whether they are in network for that specific plan for the coming year, since directories can be out of date. If you need a specific hospital or cancer center, ask about it by name.

Treatment and support options

HMO plans

Health maintenance organization plans usually ask you to choose a primary care provider and get referrals to see specialists. Apart from emergencies, urgent care and some dialysis, care outside the network is generally not covered. In exchange, HMOs often have lower premiums and copays. They tend to suit people who are happy with the plan's local doctors and do not travel for long periods.

PPO plans

Preferred provider organization plans have a network, but you can go outside it and pay more rather than nothing at all. Referrals are usually not needed. PPOs have two out-of-pocket maximums, one for in-network care and a higher combined one. They may suit people who want some flexibility or who see a specialist outside the network.

Special Needs Plans

Special Needs Plans limit membership to people with particular needs: people who have both Medicare and Medicaid, people living in a nursing home or needing that level of care at home, or people with certain chronic conditions such as diabetes or heart failure. They tailor their networks, drug lists and care coordination to those groups, and you can join only if you meet the plan's criteria.

Staying with Original Medicare

For some people the better choice is not a Medicare Advantage plan at all. If you want to see any provider that accepts Medicare without referrals or prior authorization, Original Medicare with a Medigap policy and a Part D plan may suit you better, though it usually costs more in premiums. Weigh the decision carefully, because returning to Medigap later may not be possible on the same terms.

Prevention

• Call your key doctors to confirm they are in network for the coming year
• Check how the plan handles prior authorization for care you already use
• Look at the out-of-pocket maximum as the worst-case cost of a bad year
• Be wary of unsolicited calls or ads urging you to switch plans
• Keep the plan's Evidence of Coverage where you can find it

Day to day

Living with a Medicare Advantage plan means learning its rules once and then using them. Keep the plan card with you, since you should not show your red, white and blue Medicare card for routine care. Before a planned test or procedure, ask your doctor's office whether prior authorization has been obtained; offices usually handle it, but it is worth confirming so a claim is not denied later.

Many plans offer care management, nurse advice lines and extra benefits such as dental, vision or hearing coverage. These can be useful, but they often have yearly dollar limits or their own networks, so check the details before booking. If a plan denies a service, you have the right to appeal, and plans must decide urgent requests quickly. Asking your doctor to support the appeal often helps.

For specific groups

People who travel or have two homes

Most Medicare Advantage plans cover only emergency and urgent care outside their service area. If you spend part of the year in another state, ask whether the plan has a visitor or travel program, or whether a PPO with a national network might fit better. Moving permanently out of the area gives you a chance to change plans.

People with serious or complex conditions

If you see several specialists or may need cancer treatment, check that the specific centers and specialists you would use are in network, and how prior authorization works for treatments such as chemotherapy or rehabilitation. The out-of-pocket maximum offers protection, but access to particular providers can matter even more.

People new to Medicare

If you join a Medicare Advantage plan when you first become eligible at 65, you have a trial right: within the first 12 months you can switch back to Original Medicare and buy a Medigap policy without medical questions. After that, Medigap insurers in most states may consider your health.

Questions to ask your doctor

• Are you in network for this specific plan next year, not just this year?
• Which hospitals do you admit patients to, and are they in the plan's network?
• Does the care you are recommending need prior authorization from my plan?
• Will you support an appeal if my plan denies something you believe I need?
• Are the specialists you usually refer to in this plan's network?
• Is there anything about my health that makes Original Medicare a better fit?

More questions, answered

Can a Medicare Advantage plan drop my doctor in the middle of the year?

Yes, providers can leave a plan's network during the year. Plans are generally required to notify affected members, and in some situations, such as a significant change to the network, you may qualify for a special enrollment period to change plans. If you are in the middle of treatment, ask the plan about continuing care with that provider.

What happens in an emergency when I am away from home?

Medicare Advantage plans must cover emergency and urgently needed care anywhere in the US, whether or not the provider is in network. Call 911 or go to the nearest emergency room. Once you are stable, the plan may ask that follow-up care happen in network, so contact the plan as soon as you reasonably can.

Are the extra benefits worth choosing a plan for?

Extra benefits such as dental cleanings, eyeglasses or fitness programs can be useful, but they are usually modest and can change each year. The core medical coverage, network and drug costs have far more effect on what you pay if you get sick. Treat extras as a tiebreaker between plans that already fit your medical needs.

How does prior authorization work?

Prior authorization means the plan must approve a service before you get it for the plan to pay. Your doctor usually submits the request with supporting information. Standard requests take longer; if waiting could seriously harm your health, your doctor can ask for a fast decision. If the plan says no, you can appeal.

Can I change Medicare Advantage plans if I am unhappy?

You can change during Open Enrollment each fall, and if you are already in a Medicare Advantage plan you get one further chance to switch plans or return to Original Medicare between January 1 and March 31. Certain life events, such as moving, also open special enrollment periods.

Do I still pay the Part B premium in a Medicare Advantage plan?

Yes. You keep paying your Part B premium, and the plan may charge its own premium on top. Some plans charge no extra premium, and a few use part of their payment to reduce your Part B premium. Look at the full yearly cost, including copays, rather than the premium alone.

Related topics

• Out-of-Pocket Maximum: Sorting the Evidence From the Noise (Health Insurance and Costs)
• The Evidence on Getting a Referral and Prior Authorization, Without the Hype (Using Health Services)
• The Evidence on Travel Insurance and Healthcare Abroad, Without the Hype (Travel Health)
• Sexual Health Services: What Published Guidance Supports (Sexual Health)

Where to go next

• Medicare Advantage Plans: Separating Myth From Guidance
• Medicare Advantage Plans for Beginners: Where to Start
• Medicare Advantage Plans — the reference entry
• Medicare and Medicaid: The Complete Guide
• What the Guidance Really Says About Part D and Extra Help
• Medicare Enrollment Periods: What the Evidence Actually Says

When to speak to a doctor

In an emergency, call 911 or go to the nearest emergency room; Medicare Advantage plans must cover emergency care in or out of network. If a plan denies care your doctor says you need, ask about a fast appeal.

Where this comes from

• Medicare.gov — Understanding Medicare Advantage Plans
• Medicare.gov — Compare Original Medicare and Medicare Advantage

How this page was put together

Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.

Medical disclaimer

This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.