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Medicare Advantage “101”

Medicare Advantage plans can indeed provide a very cost effective alternative to Original Medicare.  Depending on the county there may not be a plan premium and most care can be received without even a copay.  However, there are a number of issues to be aware of before enrolling.

All Medicare Advantage plans have a physician and hospital network.  If you opt for a PPO plan this is not as much of an issue as when you choose an HMO.  PPO plans will generally allow for you to see out of network providers, albeit at a higher share of cost.  On the other hand, virtually all HMO plans use a primary care physician as “gatekeeper,” to request non-urgent referrals to most specialists.

The HMO network does not mean that the physician is “in the book.”  In order to see a specialist, that doctor must be affiliated with the same medical group as your primary care doctor.  So although both Drs. Smith and Jones have a contract with your HMO, unless they are in the same medical group (think sub-network), you likely can’t see both.

In addition, your physician may be in network when the plan is effective on January 1 but as of June 1 they leave the group.  You will then have to choose another doctor.  Surprisingly, this scenario will not allow you to change or drop your plan.

In the absence of a special enrollment period the plan you choose to be effective on January1 will be the plan you remain in throughout the year.  If you chose an HMO and in April you find that a PPO would have been a better choice you still must wait until the next annual election period to make a new choice which would not be effective until the following January.

The best advice is to speak with an insurance agent that specializes in helping people with Medicare review all the options.  No one has a crystal ball but knowing your choices can minimize poor decisions.

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