Is Medicare Advantage Right for You? Outstanding Info You Should Know

Medicare Advantage can have a $0 premium

Hi, I’m Chris Duncan Independent insurance broker and run an insurance brokerage called trusted benefits direct. Today’s blog is on Medicare Advantage and could if be right for you. If you’re new to my blog, please subscribe! That way you can stay up to date for new information and other informative blogs like this one.

Many Medicare Advantage plans throughout the United States have a $0 monthly premium. You must always pay your Part B premium ($144.50 is the 2021 standard premium). There are some plans, mainly in southern California and Florida that offer a rebate of a portion of the Part B premium. We receive questions about how a Medicare Advantage plan can have a $0 premium. Private insurance companies are able to accomplish this through money sent to them by the CMS (Centers for Medicare and Medicaid Services). According to the 2021 Medicare and You handbook page 58, “ Medicare pays a fixed amount for your coverage each month to the companies offering Medicare Advantage Plans.” https://trustedbenefitsdirect.com/wp-content/uploads/2020/09/2021-Medicare-and-You.pdf

Include coverage for Medicare Part A and Medicare Part B

Medicare Advantage plans cover Medicare Part A and Part B. The Centers for Medicare and Medicaid Services (CMS) states that Medicare Advantage plans cannot charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care.

Medicare Advantage Part D Prescription Drug Coverage is Included Most of the Time

All most all companies that offer a Medicare Advantage offer Part D coverage at no additional cost. This means the Medicare Beneficiary can also receive their medical coverage from the plan.

Medicare Advantage has a Trial Period

Some Medicare beneficiaries will qualify for a Medicare Advantage trial period. There are two such instances. First, when someone has turned 65 and enrolled in a Medicare Advantage. This beneficiary has a 12-month trial right. This means anytime during the first 12 months of enrollment. The Medicare Advantage plan the Medicare beneficiary can disenroll from the plan and enroll back to Original Medicare. This change will take place on the first of the next month after the request.

For example, if the Medicare Advantage beneficiary requested to be disenrolled on May 15. The changes would become effective on June 1. In addition, if the beneficiary wishes to purchase a Medicare Supplement after disenrolling. They may do so what is called a guaranteed issue. This means there are certain Medicare Supplement plans available to purchase that are not allowed to ask any medical questions as a condition of acceptance. The Medicare Beneficiary may also be able to have all pre-existing conditions covered without a waiting period or exception.

Original Medicare: Beneficiary’s Options

The second such trial period is for those that already have Original Medicare and a Medicare Supplement. In this scenario, a Medicare Beneficiary chooses to enroll in a Medicare Advantage plan for the first time after being on Original Medicare and a Medicare Supplement. Any time during the first 12 months of being on the Medicare Advantage plan, the beneficiary may request to be disenrolled and return to Original Medicare. This scenario also triggers a guaranteed issue for the beneficiary to return back to the Medicare Supplement plan and company the beneficiary had before enrolling in the Medicare Advantage plan. If the Medicare Supplement plan or company is no longer available, the beneficiary is entitled to choose from certain plans with any company.

Additional Benefits not Covered by Original Medicare

Medicare Advantage plans cover services not covered by Original Medicare. Some of these include dental, vision, hearing, rides to services, over the counter pharmacy items.

Dental

A Medicare Advantage plan can offer coverage for dental services. This may include cleanings, fillings, extractions, dentures, etc. It is all up to the individual plan what they would like to cover. Usually, these services come with a copayment system attached to them. A copay is a fixed dollar amount a beneficiary would pay for a particular service.

Glasses

Many times in the case of glasses the Medicare Advantage plan will pay up to a fixed dollar amount per year for glasses. In additional cost will be the responsibility of the Medicare Advantage member. For example, the Medicare Advantage plan may pay up to $150 per year for glasses. Any cost of the glasses over $150 will be the responsibility of the member.

Hearing Aids

The Medicare Advantage plan may have coverage for hearing aids. For example, the company may have a $1,500 limit. And any additional cost will be the responsibility of the Medicare Advantage member.

Over the Counter Pharmacy Items

More and more Medicare Advantage plans are allowing members to choose from a list of items that would be available at a pharmacy. Depending on the Medicare Advantage company the items may include, but are not limited to.

• Cold and flu liquids
• Compression hosiery
• Lens cleaners for glasses
• Vitamins
• Ddult incontinence

The list is virtually endless. Many times what the Medicare Advantage will allow is a set dollar amount to be spent on a quarterly basis. For example, the Medicare Advantage company may allow $90 to be spent per quarter. Once per quarter, the beneficiary can fill out an order form and send it to the company providing the items. Benefits are usually administered through mail order. The benefit is usually what is a “use it or lose it” benefit. Meaning if the member does not use all of the dollar amount provided, the benefit will not carry over to the next over-the-counter benefit period. For example, if a member has $90 to use per quarter and only uses $80 in the current quarter, then they will not have $100 to spend the next quarter.

Rides to Providers/Pharmacies

Medicare Advantage plans can offer rides to and from providers and pharmacies. Most plans will offer a fixed amount of one-way trips per year. In addition, there is also a limit on the coverage distance of the ride. In most cases, the distance is adequate to see your providers and pharmacies inside of the county the beneficiary resides. The term one-way trip does cause concern for our clients who are new to the ride system. They are concerned the ride will only be provided to their doctor, and they will be responsible to get home on their own.

The reason the benefit reads one-way trips is this allows the member to make more than one stop for their health needs. If the benefit read round-trip then the coverage would likely go from their home to the doctor and return home. The one-way system allows for flexibility. For example, the member may go to their doctor and after their doctor visit, they need to go to a separate facility to have blood labs taken. After the blood labs are finished they then return home. This is an example of using three one-way trips. The one-way system certainly provides for more flexibility.

Medicare Advantage has Out of Pocket Maximum

Before I get into the specifics, it is important to understand the maximum pocket costs the member will pay out of pocket before the plan will pay 100%. I am asked sometimes if the maximum out of pocket is the maximum dollar amount of coverage the member has and after that number the member no longer has coverage. The answer is “no”. All Medicare Advantage plans have an unlimited amount of coverage.

The maximum out of pocket is the maximum dollar amount the member pays. After that number is met the plan will pay 100% of costs. The maximum out of pocket is only for medical services for Part A and B of Medicare. What a beneficiary pays for Part D prescription drug coverage does not count towards the maximum out of pocket (CLICK HERE for more about Part D limits) and also what is paid in extra benefits like dental, vision, hearing, etc. does not count.

One of The most desirable benefits is…

Maximum out-of-pocket is one of the most desirable benefits our clients find with Medicare Advantage. Outside of the $0 or low monthly premium is the maximum out-of-pocket. This maximum out-of-pocket allows the Medicare Beneficiary to have a maximum fixed dollar amount they know is the worst-case scenario for the year. Different companies can have different maximum out-of-pocket costs, but the limit the Centers for Medicare and Medicaid Services allows per year is $7,550 for in network services and $10,000 for out-of-network services.

A Medicare Advantage plan has the option to set this amount anywhere from $0 to $7,550 for in network services and $0 to $10,000 for out of network services. Now we have never seen a Medicare Advantage plan with a $0 maximum, but we do have many clients on plans with what we consider a low maximum. The lowest maximum out-of-pocket cost we have seen is $999 for the entire year. Our clients on this plan know the most they will spend in copays for the calendar year (January 1 to December 31) is $999. Once they have paid $999 out of their pocket for medical services, the plan will pay 100% of the costs for the rest of the calendar year.

Coverage Can Be Available Outside the United States

Original Medicare does not cover beneficiaries outside the United States. Although certain Medicare Supplements (Medigap) may provide emergency coverage in a foreign country. The Medicare Supplement plans that offer foreign emergency coverage is: Plans C, D, F, G, M, and N. It is up to the individual Medicare Advantage plan whether they decide to provide foreign travel coverage and what the maximum amount of coverage is. If coverage is available outside the United States the coverage is only for emergencies. Routine medical coverage is not provided with plans outside the United States. If the member does have an emergency and they are in a foreign country they are usually responsible for all of the upfront costs. They may submit medical bills to their Medicare Advantage company for reimbursement minus any deductibles and copays the plan may have.

Medicare Advantage Must Cover Anywhere in the United States for an Emergency

Most Medicare Advantage plans have some type of network the beneficiary must use. If the beneficiary receives services outside of the network for routine services most of the time the beneficiary will have to pay 100% of the costs. However, if the member has an emergency the Medicare Advantage plan must offer coverage. The same as if the emergency happened in the coverage area. Generally, there is not a reimbursement process like foreign travel emergency coverage. The member is responsible for any deductibles or copays if they apply.

Conclusion

Medicare Advantage can offer additional benefits. Original Medicare does not provide dental, vision, hearing, and other coverages and may do so with a premium as low as $0. As always, Medicare Part B premium must be paid on top of any premium even if the premium is $0. Medicare Advantage replaces Original Medicare Part A and B. And the Medicare Advantage company may not charge more than Original Medicare would charge.

Many times Part D prescription drug coverage is included as well. Medicare Advantage also provides a trial right period. A beneficiary may opt-out during the first 12 months under specific circumstances. They also provide emergency coverage anywhere in the United States and may include foreign travel emergency coverage as well. Lastly, the maximum out-of-pocket provided will limit the amount a member is responsible for before the plan will cover 100% of Medicare and Part B medical costs.

Important Info from my YouTube channel

If you have any questions about Medicare, in general, I’m here to help. I help with Medicare Supplement plans, Medicare Part C Medicare Advantage Plans, Part D Prescription Drug Plans, protecting retirees’ retirement, and much more. Again, I’m Chris Duncan and it’s easy to contact me. You can do so toll-free at 800–910–3382 and my website TrustedBenefitsDirect.com. If you found this information helpful and you probably did if you made it all the way to the end of my blog please subscribe to my blog posts. Also, please don’t forget to subscribe to my YouTube channel. You can see the link below. Make a comment or share on your social media like Facebook and Twitter. I’m always putting out information to help with things like Medicare basics, Medicare Made Clear, Medicare Explained, Medicare 101, and much more. Thanks again and I’ll be talking with you soon.

Medicare can be a tricky subject. My videos and articles have been featured on ABC, NBC, CBS, and Fox. I blog and make videos to help with understanding Medicare and how to best choose Medicare Supplements, Medicare Advantage Part C, and Part D Prescription plans. We are independent and we get to represent almost all the “A” rated companies. I am here to help others with the knowledge I have gained helping thousands with Medicare questions. We provide help through all 50 U.S. States, including Washington D.C and Puerto Rico. If you would like to experience our free, no-obligation, stress saving service gives us a call on our toll-free number at 800–910–3382, or if you just need to ask us a quick question send a text to our special text-only number at 702–514–6625.

Originally published at https://trustedbenefitsdirect.com on May 7, 2021.