The introduction of Medicare revolutionized the wellness program in the US. Through this system, turning 65 means that you’re entitled to specific healthcare benefits from the government.
1995 saw the launch of Medicare Advantage, created by the federal government, to provide Americans with more options. Unlike original Medicare, these wellness plans are sold by private health insurance companies and regulated by the authorities.
To fully understand the benefits of these schemes, we have to look at how it’s different from original Medicare.
What is Medicare Advantage
These plans offer the same benefits as Medicare Parts A and B, as well as extra coverage. This often includes prescription drugs, dental, vision, and in some cases, even gym memberships. For a comprehensive look at what it offers, take a look at the Medicare Advantage plan on this link.
As an enrolled beneficiary, you pay Part B premiums plus the surcharge of your Medicare Advantage plan (if applicable). This type of coverage can be an HMO (health maintenance organization), PPO (preferred provider organization), or private fee-for-service policy. It must be approved and follow the guidelines of Medicare.
Medicare has an annual open enrollment period from the 15th of October to the 7th of December. During this time, beneficiaries are given the option to switch from Medicare to Advantage, and vice versa. The change will take effect on the 1st of January.
The Difference Between Medicare Advantage And Original Medicare
Out-Of-Pocket Cost
Medicare only covers a certain amount of days spent in a hospital, and there are no set limits to the amount you have to pay out-of-pocket.
Medicare Advantage, however, has a yearly maximum out-of-pocket dollar amount. When reached, your plan will pay in full for most of the services covered by it.
Coverage
Advantage plans cover all hospital and medical costs. On top of this, it also pays for vision, dental, prescription drugs, and hearing expenses.
Travel Cover
In general, Medicare only covers you as long as you’re within the borders of the US. With Advantage, you’re covered regardless of where you are. These plans typically have a lifetime amount of $50,000 to cover emergency care.
Medical Network
Original Medicare allows you the freedom to visit any clinic or doctor that accepts it. Medicare Advantage has a fixed network of medical facilities and doctors which you’re bound to. In certain rare cases, you’ll be allowed to get care outside of the system, but strict rules apply to this. It will also come at an extra out-of-pocket cost to you.
Copay as Opposed to Coinsurance
Original Medicare comes with coinsurance. This means that you’re responsible for 20 percent of the general health service cost, such as outpatient surgery or doctor visits.
Advantage, however, has a copay amount. This is a fixed cost that you’re responsible for, regardless of the expense to your health insurance. Typically this amount ranges between $15 and $20 per visit to a clinic or doctor.
The Pros And Cons Of Medicare Advantage
Pros
- Added benefits include coverage for hearing aids, routine vision care, prescription drugs, regular dental care, and fitness center membership.
- It may cost you less. The co-payment of Medicare Advantage is, on average, $15 per visit. In contrast, Medicare coinsurance is 20 percent of the total expense. This typically works out to be quite a bit more. You also have a total out-of-pocket dollar amount. When reached, you pay nothing for covered medical services for the rest of that year.
- Coordinated health care – These plans are managed care with networks of contracted health care providers. HMO policies, for instance, need you to choose a primary physician to help coordinate your wellness program. Coverage that includes prescription drugs also offers medication therapy management. This added benefit can prove to be invaluable to your health.
- A one-stop center for your health care and prescription drug needs. Most plans also include Part D (prescription drugs) coverage on top of Parts A, B, and C of Medicare. For this reason, it’s convenient to work with one policy administrator.
Cons
- Limited freedom of choice. Medicare Advantage plans restrict you to using their provider networks. Medical services outside of this system may not be covered, leaving you responsible for the total amount of the costs incurred.
- A doctor’s referral and plan authorizations may be required for specific services and procedures. This includes visiting specialists, home health care, hospital stays, certain complicated processes, and medical equipment.
- You’re limited to specific service areas. These schemes typically have regional networks of participating providers. To qualify, you need to live at least six months of the year in a specific plan’s service area.
Is Medicare Advantage The Better Option?
The only question that remains unanswered is whether Medicare is the better option?
Unfortunately, the answer isn’t a simple ‘Yes’ or ‘No”. The truth is that these schemes offer benefits that a lot of people find attractive. Then certain other aspects may not suit your lifestyle or personal preferences.
Overall, Medicare Advantage plans provide affordable health care with more coverage. The downside is that you’re bound to the scheme’s rules and limited to its service providers’ network.
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