Site Links HomeMedicare BasicsBlog ArticlesFind an AgentTurning 65 Medicare Answers Call a Local AgentFind the Right Plan LEGAL Privacy Policy©2020 LMS Insurance, LLC – All Rights Reservedperson with Medicare Advantage questions asking a help desk support agentPublished on: 11/02/2023

4 Medicare Advantage Concepts Explained

We’re right in the middle of the 2023 Annual Enrollment Period, and that means a ton of talking about Medicare! You’re probably getting inundated with phone calls, advertisements, and social media messages about reviewing your Medicare plans. With all this information floating around, it’s also the time of year when people are most confused about Medicare.

Today, we’re going to address four Medicare Advantage concepts you should know more about.

man explaining Medicare Advantage concepts to another man

1. Original Medicare versus Medicare Advantage

Let’s tackle the biggest debate first: Original Medicare versus Medicare Advantage. At some point, every Medicare beneficiary wants to know the difference between these two Medicare options. Original Medicare is made up of Parts A and B. Most of the time, people choose to add a Medigap plan and a Medicare Part D prescription drug plan.

Instead of building a health insurance portfolio with multiple plans, some people opt for Medicare Advantage instead. Medicare Advantage (also known as Medicare Part C) takes the place of Original Medicare and builds in lots of extra benefits. If you enroll in Medicare Advantage, you won’t need a Medigap policy or a separate Part D plan (in most cases). 

There are pros and cons to each option, so be sure to discuss this thoroughly with your Medicare advisor.

2. Out-of-Pocket Costs

Beneficiaries who have Original Medicare without a Medigap plan or Medicaid are taking a big risk when it comes to out-of-pocket costs. There is no cap on your expenses if you have Original Medicare alone. While it does offer great coverage, including 80% coverage on outpatient costs, your 20% can amount to a lot. Think about cancer treatments, radiation, big surgeries. Those are all large expenses where 20% of the cost could be huge. Be sure to cap those expenses with a Medigap or Medicare Advantage plan.

With a Medicare Advantage plan, you’ll have some copayments or coinsurance costs when you receive care. Small things like visits to your doctor, lab tests, and x-rays usually have relatively low costs attached to them. The great thing about Medicare Advantage plans it that they all have a Maximum Out-of-Pocket or MOOP. Once you hit your MOOP, the plan pays 100% of approved services.

3. Prior Authorization

Original Medicare has prior authorization guidelines that are also followed by Medicare Advantage plans. Sometimes, Medicare Advantage plans require more prior authorizations than Original Medicare. While some see this as a negative (and we can’t deny that), it shouldn’t keep you from enrolling in Medicare Advantage.

Yes, prior authorizations can delay your treatment, and they’re a pain for medical billing teams. However, they’re in place to try to keep your healthcare costs as low as possible. Plus, if the alternative is Original Medicare alone, we’d never recommend that. What some people don’t realize is that not everyone can afford a Medigap plan, and some people are not eligible to have one. In those cases, Medicare Advantage is the best option.

4. Step Therapy

Step therapy is used in both Medicare Advantage and Medicare Part D plans. Similar to the prior authorization feature, this method is used to help control costs. When step therapy applies to a medical treatment or prescription, it requires the beneficiary to try a lower-costing option before approving a more expensive one.

Get Your Medicare Advantage Questions Answered

Medicare Advantage is a big topic that requires lots of conversations between you and your Medicare advisor. Need an advisor? Local Medicare Specialists has a team of agents near you. Our advisors understand Medicare Advantage front to back, and are especially familiar with the Medicare Advantage plans in Arizona. Call today to chat with a Medicare advisor near you.

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