Medicare Advantage (MAPD) combines Medicare Parts A, B and D (prescription drug coverage) together into one plan, referred to as Part C. These plans have become increasingly popular over the past decade due to the inclusion of many benefits not provided by Original Medicare (Part A + Part B), including dental, vision, transportation, ability to order over-the-counter products and some plans even help beneficiaries for their monthly Part B premium. These plans also provide financial protection by limiting the out-of-pocket costs a beneficiary is required to pay each year for Medicare services. 

Enrollment in Medicare Advantage has almost doubled over the past decade. In 2019, one-third (36%) of all Medicare beneficiaries (i.e. 22 million people) were enrolled in a Medicare Advantage plan. Between 2018 and 2019, total Medicare Advantage enrollment grew by about 1.6 million beneficiaries, or 8 percent. The Congressional Budget Office (CBO) projects that the percentage of beneficiaries enrolled in a Medicare Advantage Plan will rise to about 47% by 2029. 

In total for 2021, there are 3.550 different Medicare Advantage plans available nationwide for individuals to enroll in. This represents a 13% increase (402 more plans) compared 2020. This is a good thing for Medicare beneficiaries, because each different plan offers a slightly different combination of benefits- allowing consumers to the leverage to shop around for the plan that best fits their lifestyle and health care needs.

While a Medicare Advantage plan can be a great option for Medicare beneficiaries, enrolling in the wrong plan can potentially cause problems. It is therefore necessary to carefully evaluate the plan’s specifics plan before enrolling. Following is a checklist of things that you should consider prior to choosing a Medicare Advantage plan:

Do all your doctors accept the plan?

Every MAPD plan has a network of physicians, hospitals and other health care providers. It is important to make sure that all providers you routinely use are in the plan’s network. 

Do you typically have multiple specialist physician appointments each month?

• Most MAPD plans have a $0 copay for primary care physicians but can charge up to $50 per visit to see a specialist.
• If you typically see several specialists per month, you may want to consider an MAPD plan that has a lower specialist copayment.
• Some MAPD plans charge as low as $15 or $20 to see a specialist.

Are all your medications covered by the plan?

It is easy to view the cost of your medications by using the “Medicare.gov” site. Because medication formularies and prices vary greatly from plan to plan, take time to compare plans to determine which provide the best deal. 

Does the MAPD plan have a yearly deductible for medications?

• Some plans have a yearly prescription drug deductible for certain medications (usually for tiers 3-5 or may include tiers 2-5). 
• The prescription drug deductible can range from $0 to $445 per year.
• Be sure to access the “Medicare.gov” website to evaluate the cost of your medications each month, and to determine if a yearly deductible will apply.

Do you need transportation services?

Some plans provide a transportation benefit which allows beneficiaries to call the company to request transportation to and from a scheduled medical appointment. 

Do you need a good dental, vision or hearing coverage plan?

Most Medicare Advantage plans provide some level of dental, vision and hearing coverage, but the degree of coverage each provides varies greatly. Examples of dental coverage provided by MAPD plans:

• Some plans provide coverage for routine check-ups but charge high copayments if comprehensive work of any kind is performed (be sure to ask what dental procedures are covered and how much out-of-pocket cost is required upfront). 
• Some plans allow for a predetermined amount of coverage for any dental services (from any dental provider) but require that you pay for the service(s) upfront and then file for reimbursement.
• Some plans allow for a predetermined amount of coverage at a “network” dental provider (which may or may not include the dentist you are currently using). The amount of allowed coverage varies from $750 to $1500 per year and is billed directly to the MAPD company by the provider. For beneficiaries with Medicare and Medicaid coverage, as much as $2,000 to $4,000 per year for comprehensive dental coverage is available.
• Some plans do not provide dental coverage but can be purchased for a monthly premium.

     Examples of vision coverage provided by MAPD plans:

• Most plan provide for a $0 cost vision exam each year.
• Most plans have a network of vision providers that you must use.
• Many plans provide $100 to $300 per year to purchase glasses or contacts. For beneficiaries with Medicare and Medicaid coverage, plans can provide up to $500 per year of eyeglasses or contacts.
• Some plans provide a set amount of money for eyeglasses or contacts but require that you make the out-of-pocket purchase and then send in the receipt for reimbursement.

Do you need help paying for your Part B monthly premium?

• Some MAPD plans provide $30 to $70 per month to assist paying for your Part B monthly premium (i.e. typically $148.50 per month). This benefit is referred to the “Part B Buy Down”.
• MAPD plans that offer this benefit will pay the predetermined amount of your Part B premium directly to CMS, which decreases the amount you are responsible for.
• For example, if the “Part B Buy Down” benefit is $50 per month, the MAPD plan will pay $50 of your Part B premium and you will pay only $98.50 per month ($148.50 - $50 = $98.50). The extra $50 will remain in your checking account.

Are you aware of the difference between an HMO, PPO, PFFS, and SNP MAPD plans?

• There are different types of Medicare Advantage Plans: 
• Health Maintenance Organization (HMO) Plans
• Preferred Provider Organization (PPO) Plans
• Private Fee-for-Service (PFFS) Plans
• Special Needs Plans (SNPs)
• Medical Savings Account (MSA) Plans

It is very important to understand how each plan type works before deciding to enroll. If you make a wrong decision, it may not be possible to correct it until the next year.

Health Maintenance Organization (HMO):

An HMO Medicare Advantage Plan generally provides health care coverage from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). A network is a group of doctors, hospitals, and medical facilities that contract with a plan to provide services. Most HMOs also require you to get a referral from your primary care doctor for specialist care, so that your care is coordinated. 

Can I get my health care from any doctor, other health care provider, or hospital? 

No. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network, (except for emergency care, out-of-area urgent care, or temporary out-of-area dialysis, which is covered whether it’s provided in the plan’s network or outside the plan’s network). Therefore, if you choose an HMO MAPD plan, you may be denied service from out of network physicians and medical facilities.

HMO Point-of-Service (HMO-POS):

An HMO-POS plan is like an HMO plan with the exception that you can possibly get health care outside of the plan’s network. However, you will likely have to pay a higher copayment of coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed. In most cases, you need to choose a primary care doctor. Certain services, like yearly screening mammograms, don’t require a referral.

A Medicare Advantage Plan that has a network of doctors, specialists, hospitals, and other health care providers you can use, but you can also use out-of-network providers for covered services, usually at a higher cost. 

Can I get my health care from any doctor, other health care provider, or hospital? 

Yes. PPO plans have network doctors, specialists, hospitals, and other health care providers you can use, but you can also use out-of-network providers for covered services, usually for a higher cost. You’re always covered for emergency and urgent care. If you choose to use services from an out-of-network provider, it is important contact the physician or plan administrator in advance to ensure that the services are medically necessary and that your plan will cover them.

With a PFFS plan, you can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms and agrees to treat you. If you join a PFFS plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan’s terms, but you may pay more. Before you get any services, ask your doctor or hospital if they can contact the plan for payment information and accept the plan’s payment terms. If you need emergency care, it’s covered whether the provider accepts the plan’s payment terms or not. 

By agreeing to accept the a PFFS plan, the provider must agree to follow the plan’s terms and conditions for payment and bill the plan for the services they provide for you. However, it is important to understand that an out-of-network provider has the option to decide at each subsequent visit whether to accept the PFFS plan’s terms of payment for their medical services. If requested by the provider, you may have to pay an additional amount (up to 15% more) if the PFFS plan allows providers to “balance bill” (i.e. when a provider bills you for the difference between the provider’s charge and the amount allowed by the plan).

Do PFFS plans cover prescription drugs? 

Sometimes. If you want Medicare prescription drug coverage, and it’s offered by the PFFS plan you enroll in, you must get your drug coverage from that plan. 

If your PFFS plan doesn’t offer drug coverage, you can join a separate Medicare drug plan if you choose to do so.

A Special Needs Plan (SNP) provides benefits and services to people with specific diseases, certain health care needs, or limited incomes. SNPs tailor their benefits, provider choices, and list of covered drugs (formularies) to best meet the specific needs of the groups they serve. SNPs can be either an HMO or PPO plan, and cover the same Medicare Part A and Part B benefits that all Medicare Advantage Plans cover. However, SNPs might also cover extra services tailored to the special groups they serve. For example, if you have a severe or chronic condition, like cancer or chronic heart failure and you require a hospital stay, a SNP may cover extra days in the hospital. 

Who can Quality for a SNP plan?

You may qualify for an SNP if you live in the plan’s service area and meet one of these requirements: 

• If you have one or more of the chronic illnesses listed below, you may qualify for a Chronic Condition SNP (also referred to as a C-SNP):
• Chronic alcohol and other dependence 
• Autoimmune disorders 
• Cancer (excluding pre-cancer conditions) 
• Cardiovascular disorders 
• Chronic heart failure 
• Diabetes mellitus 
• End-stage liver disease 
• End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis) 
• Severe hematologic disorders 
• HIV/AIDS 
• Chronic lung disorders 
• Chronic and disabling mental health conditions 
• Neurologic disorders 
• Stroke
• I you’re eligible for both Medicare and Medicaid (also called a Dual Eligible SNP or D-SNP).
• Each SNP limits its membership to people in one of these groups, or a subset of one of these groups. You can only stay enrolled in an SNP if you continue to meet the special conditions that the plan serves. 



Can I get my health care from any doctor, other health care provider, or hospital? 

HMO and PPO SNP plans follow the same provider network rules as other HMO and PPO plans. However, Chronic Condition SNP plans typically have more physicians specialized in treating certain chronic health conditions included in their network.