Keys to Your Best Advantage Plan

The Advantage Plan Shopping Season

‘Tis the season. No, not Christmas season; instead, ‘tis the season to hear those Advantage Plan commercials. And it’s almost the season to shop Advantage Plans.

If you are currently on an Advantage Plan, or if you are currently on Original Medicare (and, most likely, on a prescription drug plan), and are open to a “better deal,” then your shopping season is nearing. That “shopping season” is, technically, called the Annual Enrollment Period (AEP), and it lasts from October 15 through December 7.

What You Can Do During AEP

So, what can you do during AEP? During this Annual Enrollment Period, you can disenroll from an Advantage Plan and return to Original Medicare, or you can enroll on a prescription drug plan (which will automatically replace the drug plan you currently have or the Advantage Plan you currently have—if that Advantage Plan has a drug plan within it) or an Advantage Plan (which will automatically replace the Advantage Plan you currently have). Any plan on which you enroll during this period will begin January 1.

By the way, you only get one choice during AEP, so make it a good one. Once you choose a new plan, it is locked in to begin January 1. (However, if you feel you have made a mistake by enrolling on a particular Advantage Plan, you may disenroll from that plan between January 1 – February 14. Once you do, you will return to Original Medicare and will have the option of choosing a drug plan at that time.)

Open to a Different Medicare Advantage Plan?

If you currently have a Medicare Advantage Plan, and if you like how that plan works for you, you do not have to change it. You can simply do nothing, and your plan will roll over into next year.

However, it is good to keep in mind a few things about Advantage Plans. First, even if you like how your plan works for you, you still may not be able to keep it. From time to time plans go away in specific service areas. That means you could receive a notice that your particular plan will not be available in your area for 2017. If that happens, you will have no choice but to enroll on a different plan or return to Original Medicare.

Second, even if you like how your plan has worked in 2016, your Advantage Plan could make changes for 2017 that you don’t like. When you receive notification of changes to your plan, make sure you look over those changes carefully; or contact your insurance agent, and ask him to explain the plan changes for 2017. (If your agent seems unaware of those changes, or if he or she does not seem interested in taking the time to meet with you about those changes, it may be time to find another agent—one who has your best in mind.) It is very important that you are comfortable with those changes before you decide to keep your plan for 2017.

What to Look for in an Advantage Plan

When shopping Advantage Plans, you will want to keep in mind some important keys to getting the Advantage Plan that is best for you. First, only look at Advantage Plans in your service area; that is, make sure your zip code is included in the service area of any Advantage Plan you look at. For you cannot enroll on a plan outside of your service area. (PPO Advantage Plans tend to have a bigger service area than do HMO Advantage Plans. By the way, if you are not now on an Advantage Plan, but would like to enroll on one, you will need to have Medicare Parts A & B, be in the service area of any plan on which you enroll, and you must NOT have End-Stage Renal Disease [ESRD].)

HMO Advantage Plan vs a PPO Plan

Second, make sure your doctors are in the network of the Advantage Plan in which you are interested. If you are looking at an HMO plan, you must see doctors within the network in order to be covered by the plan. (Seeing a doctor outside of the HMO network means you will pay 100% of the bill.) With a PPO plan, you can go out of network to see doctors, but you will pay more for those doctor visits.

Keep in mind that an HMO Advantage Plan works differently than a PPO plan does. With an HMO plan, you must get a referral from your primary care physician in order to see a specialist (or to get other medical treatment)—or else the visit or treatment is not covered—with a PPO Advantage Plan, a referral is not typically required. This is an important distinction, particularly, if you want more choices in seeing specialists.

Know Your MOOP

Third, do NOT enroll on an Advantage Plan based on its premium. Yes, a zero premium is nice, but keep in mind that an Advantage Plan is a cost-sharing plan, meaning you will have copays when you use the plan. Make sure you know what those copays will be and what your maximum out-of-pocket (MOOP) cost could be.

The MOOP on a plan is the maximum amount you could be out of pocket in any calendar year. For example, the plan in which you are interested may have a MOOP of $6,700. So, even if the Advantage Plan has a low (or no) copay for your primary care physician office visit, if you are in the hospital a few times and have out-patient tests (especially high-dollar tests, such as MRIs and CT scans) and see several specialists, you could end up owing $6,700. Are you comfortable with that? Can you afford it? At least make sure you think through these issues before enrolling on an Advantage Plan.

Need More Help?

In shopping for an Advantage Plan, it can be to your advantage (no pun intended) to sit down with an independent agent who represents two or more Advantage Plans. If you are interested in looking at another (one other than the one in which you are currently enrolled) plan, make sure your agent goes through ALL of the summary of benefits, explaining each benefit to you. That way, there will be no surprises later. (Generally speaking, Advantage Plan surprises are not a good thing.) Of course, there still could be questions later, so, hopefully, you pick an agent who will return your calls and patiently answer any and all questions you may have.

When shopping for an Advantage Plan this AEP, keep in mind these key points of information. If you do, your Advantage Plan experience should be a better one. So, here’s to happy shopping!


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