Medicare Advantage Plans

Evan Gold October 17, 2012 2
Medicare Advantage Plans

By Bonnie L. Quick

What is a Medicare Advantage Plan and how does it differ from straight Medicare? How do you sign up and when? The open enrollment period for the 2013 coverage period will run from October 15-December 7, 2012.

Medicare recipients need to examine their plans annually to determine whether they have the best plan for their current needs. Many seniors and disabled do not realize that they must make a choice to elect Original Medicare or a Medicare Advantage Plan (Medicare Part C) every year.

Medicare is a federally administered insurance plan that guarantees health insurance for Americans ages 65 +and younger people with disabilities as well as people with end stage renal disease.  It consists of four parts.

Medicare Part A helps pay for in-hospital stays, part-time home health care, skilled nursing facility and certain medical equipment. Part A is generally available without a monthly premium.

Medicare Part B helps pay for medically necessary physician visits, outpatient hospital visits, home health care costs, and other services for the aged and disabled.

Medicare Part C (Advantage Plan) offered by private companies that contract with Medicare to provide you with both Part A and Part B benefits. Most Advantage Plans also include Part D (Drugs) as well as other services like gym membership.

Medicare Part D is for prescriptions.

The most common Medicare Advantage Plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations, Private Fee-for-Service (PPO) and Special Needs Plans, (SNPs.)


In HMO Medicare Advantage Plans, generally you must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost.

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.

In most cases you need to choose a primary care doctor in HMO Plans.


In a PPO Medicare Advantage Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. Each plan allows the flexibility to go to doctors, specialists, or hospitals out of network, at higher cost.

In most cases PPO Plans have network doctors, other health providers, and hospitals from where you will usually get your care.

As a rule, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember to check to be sure you are covered.

You don’t need to choose a primary care doctor in PPO Plans and in most cases, you don’t have to get a referral to see a specialist in PPO Plans, within the plan.

PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.


In a Special Needs Medicare Advantage Plan Medicare Part A and Part B health care services are available to people who can benefit the most from things like special care for chronic illnesses, care management of multiple diseases, and focused care management.

These plans are usually available free of charge for low-income dual eligible people on both Medicare and Medicaid. They also may limit membership to ones who live in certain institutions (like a nursing home), or that have certain chronic or disabling conditions.

Some of the SNPs allow money for eyeglasses and dental work.

This is by no means a comprehensive list. Consult with a professional if you have questions. Remember to take your time and don’t commit to anything you don’t understand.


  1. susan sara October 29, 2012 at 12:40 am - Reply

    Does straight medicare pay for gym membership? Are Advantage programs the only programs that do so?

    • Evan November 26, 2012 at 4:45 pm - Reply

      That is pretty correct. However to get the best information contact Hillary or David at 877-864-0263. They can answer all insurance questions.

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