Medicare Advantage Plans vs. Medicare ABD
Medicare Advantage plans, which rolled out in 2003, were designed to provide more coverage for Medicare recipients than Part A and B. The plans allow you to combine all your Medicare coverage into a singular plan, thus saving you money by not purchasing Part B (outpatient hospital and physician coverage) and Part D plans (pharmacy prescription drugs). Plus many advantage plans have additional coverage items.
Key Takeaways:
A Medicare ABD person may pays more for their plan than most advantage plans charge monthly and typically the coverage does not include dental hearing or eye care.
Advantage Plans are a better spend for your healthcare dollars, particularly because they offer coverage for additional services (dental, hearing, eye care, etc.)
Medicare ABD has a 20% copay after meeting the deductible, but does have an out-of-pocket maximum.
Standard features of Advantage plans include:
Part A, inpatient hospital, rehab hospital, nursing home coverage
Part B outpatient hospital and physician services as well as DME items (durable medical equipment)
Part D pharmacy prescription drugs
Additional coverage in some Advantage plans
Dental
Eye care and glasses
Hearing and hearing aid’s
International travel coverage for Emergency room, Urgent Care, Inpatient stay’s (you must pay and then send copied bills and proof of payment to your insurance company for them to reimburse you).
Advantage plans Types
PPO plans that allow you to choose your physicians within your insurance coverage network.
HMO plans where you have a primary physician who is the gatekeeper to your care and referrals to specialist
Some Carriers also may cover multiple states that allows you to branch out of your in-network service area. This can be useful if you are moving, work in different states, have a time-share or you are a snowbird, or simply frequently spend long stays with friends or families in other states.
Comparison of Medicare A,B,D and Advantage plans
Doctor and Hospital choices
Medicare has no restrictions on who you can see for doctor or hospital as long as they are participating providers in the United States and accept Medicare reimbursement
Advantage plans have a specific in-network area or service area that you must choose from, and you need to ask the providers if they accept the plan that you have chosen. Unfortunately many physician practices, Dentist, and opticians do not accept certain advantage plans
Cost
Medicare
Medicare Coinsurance is usually 20% of the approved amount
Medicare premium is paid monthly out of fund like SSI or personal accounts. You pay Part D separately as an additional premium added to your Part B carrier plan. You can also purchase a Medi-gap (e.g. AARP) policy to help with costs, which is a separate expense.
Medicare has no yearly limit for out-of-pocket expense, but if you purchase a supplemental policy it would pick up some of the additional costs.
Advantage plan
Advantage plans vary from a percentage to a specific copay amount. They usually have lower out of pocket costs for specific services. Part D is included in the plan coverage as well as some additional medical services.
Advantage plans also are paid monthly from SSI or personal accounts and there could be some out-of-pocket premium costs depending on the plan chosen.
Advantage plans have a yearly limit on out-of-pocket expense, once the limit is reached you will pay nothing for services Part A or Part B. Medi-gap insurance is not allowed to be purchased and you won’t need it with Advantage plans.
Coverage
Medicare
Medicare covers most medically necessary supplies and services. Medicare does not cover dental, eye, hearing care.
Medicare does require approval for some DME items, and pre-authorization for surgery/procedures but denials only occur when the item is not able to be proven to be ordered by a physician for a medically necessary reason.
Medicare does not have coverage for outside of the US. You would need to look at a Medi-gap policy for coverage.
Advantage
Advantage covers the same as Medicare for medically necessary services. They also have additional service coverage for dental, eye, and hearing care.
Part D drug coverage is included in the plan. You can have a small amount to pay for the medication depending on the tier the drug falls in as well as the diagnosis. Be sure to have all medications ready to list and have approved at the time of accepting an Advantage Plan so that you know what if any additional cost there might be.
Advantage plans do require approvals for services and pre-authorizations for surgery/procedures.
Advantage plans may offer coverage for Urgent care, Emergency Room, and Inpatient stays when part of an emergency room visit. You will need to ask the insurance agent specifically about Foreign Travel Coverage.
