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The Essential Guide To Medicare Advantage

Medicare is a federal health insurance program covering eligible adults over 65 and people with specific disabilities. Original Medicare, also known as fee-for-service Medicare, consists of Part A (hospital insurance)…

July 22, 2022

Written by Gary Martin

Medicare is a federal health insurance program covering eligible adults over 65 and people with specific disabilities. Original Medicare, also known as fee-for-service Medicare, consists of Part A (hospital insurance) and Part B (medical insurance). These two parts cover various medical services and supplies, from doctor visits and hospital stays to preventive care.

An alternative to Original Medicare, known as Medicare Advantage, has become the go-to program for more than 26 million people in 2021. Medicare Advantage plans are another way to receive your Medicare Part A and B benefits. They’re offered by private insurance companies and provide a more comprehensive level of coverage for many enrollees.

Read through the article to learn everything you need about Medicare Advantage, including what it is, what it covers, and how to enroll. We’ll also discuss the pros of this form of Medicare and the details of two popular health insurance options: Medicare for Veterans and Medicare Special Needs. We’ll provide you with the information you need to make the best decision about your health care.

What Is Medicare Advantage?

Medicare Advantage is a type of health insurance offered by private insurance companies and approved by the Centers for Medicare & Medicaid Services (CMS). It’s also known as Part C of Medicare. Medicare Advantage plans must guarantee coverage that’s at least equivalent to Original Medicare. However, most Medicare Advantage plans offer additional benefits.

These plans typically have network providers, so you’ll need to use in-network doctors and hospitals to avoid paying higher out-of-pocket costs. They also limit what you’ll have to pay out-of-pocket yearly for covered services.

What Does Medicare Advantage Cover?

As mentioned, Medicare Advantage plans include all the same services as Original Medicare (Part A and Part B). In addition, most of them offer extra coverage. The type of supplemental coverage varies by plan, but it may include:

  • Routine dental and vision care
  • Hearing aids
  • Wellness programs (like gym memberships or discounts)
  • Prescription drug coverage
  • Transportation to doctor’s appointments

While these plans commonly don’t cover out-of-the-country medical care, some may offer coverage for emergency or urgent care services outside of the United States. You should know that certain chronically ill members can have their benefits packages tailored by Medicare Advantage companies. They may include extra services to help address enrollees’ health needs.

What Does Medicare Advantage Not Cover?

Medicare Advantage plans don’t cover everything. For example, their benefits don’t typically include:

  • Clinical trials
  • Hospice services
  • Some new benefits that come from legislation or national coverage determinations

The plan can choose not to cover a particular service as long as it’s not essential to the Medicare contract. When you require a service that the plan says isn’t medically necessary, you’ll likely have to pay for it. Still, you can always appeal the decision. Check with your provider before getting any service if you’re unsure whether it’s covered.

Medicare Advantage Eligibility

To be eligible for a Medicare Advantage plan, you must enroll in Medicare Part A and B. The requirements for Part A and Part B differ depending on your age and whether you have a disability. You’re eligible for Medicare if you’re 65 or older and:

  • You’ve worked and paid Medicare taxes for at least ten years.
  • You or your spouse is currently employed and paying Medicare taxes.

On the other hand, if you’re under 65, you may be eligible for Medicare if:

  • You have End-Stage Renal Disease (ESRD).
  • You have amyotrophic lateral sclerosis (ALS).
  • You obtain a disability pension from the Railroad Retirement Board.

Plus, most Medicare Advantage plans require you to live in the plan’s service area, although some plans offer coverage nationwide.

When Can I Sign Up For Medicare Advantage?

If you’re eligible for a Medicare Advantage plan, you can enroll during one of the following enrollment periods:

  • Initial Enrollment Period: When you first become eligible for Medicare.
  • Open Enrollment Period: From October 15 to December 7 each year. The first day of your coverage will be January 1.
  • Medicare Advantage Open Enrollment Period: From January to March each year, you can switch from one Medicare Advantage plan to another or drop your Medicare Advantage plan and return to your Original Medicare.

How To Enroll In Medicare Advantage

If you’re seeking to enroll in a Medicare Advantage plan, the first step is choosing the proper one. You can compare plans on the Medicare Plan Finder tool on the official Medicare website. You can also work with a licensed insurance agent to help you compare options and find one that meets your needs.

Once you’ve found a plan, contact the provider to find out if you can enroll online or if you’ll need to complete a paper application. After receiving the corresponding form, fill it out and send it back to the provider. You’ll need to give your Medicare number and the date your Part A and B coverage began. Then, wait for a confirmation from your provider that you’re enrolled in the plan.

Medicare Advantage Costs

The cost of Medicare Advantage plans varies depending on the plan you choose and the benefits included. Most plans have a monthly premium and your Part B premium, and some require a deductible. You’ll also be responsible for copayments or coinsurance for services like doctor’s visits, prescriptions, and lab tests.

Your pay will depend on the service provided and whether it’s considered preventive, routine, or urgent/emergency care. Some Medicare Advantage plans offer $0 premiums, but these plans typically have higher out-of-pocket costs. It’s essential to contrast the prices of different plans before enrolling to ensure you’re getting the best value for your investment.

The Pros And Cons Of Medicare Advantage Compared To Other Health Insurance Plans

Medicare Advantage plans have a lot to offer, but they’re not suitable for everyone. Here are some pros and cons to consider before enrolling in a Medicare Advantage plan:


  • Most plans have lower out-of-pocket costs than the Original Medicare.
  • Many plans offer extra benefits like dental, vision, and wellness programs.
  • Some plans have $0 premiums.
  • You can receive all of your care from one provider network.


  • You may need to pay a deductible.
  • Your doctor visits may be limited to specific locations.
  • You might need prior approval from your plan before getting a particular service.
  • Your coverage may not include out-of-country medical care.

Medicare For Veterans

Veterans have access to a wide range of health care benefits through the Department of Veterans Affairs (VA), but several other health care options are available. One of these is Medicare Advantage. For veterans approaching retirement age, it’s common to wonder if they should enroll in Medicare Advantage or stick with their VA benefits.

Medicare doesn’t coordinate with the VA, so the answer to this question depends on the specific benefits offered by each plan and the veteran’s overall health care needs. Keep in mind that you can only use VA benefits in VA facilities, while Medicare Advantage plans allow you to receive care from a broader range of providers. Therefore, many veterans may find that enrolling in both programs will help them get well-rounded coverage.

Medicare Advantage Special Needs Plan

A Special Needs Plan (SNP) is a class of Medicare Advantage plan specifically designed to meet the needs of groups of people with unique circumstances. For example, people who have chronic conditions like diabetes or heart disease or those who live in a nursing home or assisted living facility. Medicare SNPs customize their benefits and networks to provide the best possible care for these enrollees.

In most cases, SNPs will require you to choose a primary care physician from their network and get referrals for specialists. You’ll also likely have lower out-of-pocket costs than you would with a traditional Medicare Advantage plan. Enrolling in an SNP can help you get the extra coverage and services you need to stay healthy and manage your chronic condition.

Is Medicare Advantage The Best Option For You?

The answer to this question is difficult to determine without knowing your specific needs and situation. To tell if Medicare Advantage is the best option for you, you should research the various plans available and compare them to other health insurance options. If you’re not up for the task or want to feel even more confident about your decision, consider working with a health insurance advisor to get more information.

When you’re ready to enroll in a plan, carefully read the plan’s enrollment materials to comprehend all of the terms and conditions associated with the coverage. There’s no one-size-fits-all option when it comes to insurance, but here are some things you should ask yourself before deciding:

  • What are my healthcare needs?
  • Can I see my preferred doctors with this plan?
  • What is my budget for monthly premiums and out-of-pocket costs?
  • Am I willing to switch pharmacies or health care providers?

Nesso Senior Benefits – Your Trustworthy Medicare Advisors

At Nesso Senior Benefits, we’re a team of Medicare experts passionate about helping people navigate the complex world of health insurance. We’re here to assist you in understanding your options, comparing plans, and enrolling in the coverage that’s right for you. With information overload and ever-changing rules, Medicare can be overwhelming; but we believe it doesn’t have to be with the right advice.

Our partners are highly knowledgeable and experienced in all aspects of Medicare. They’ll check in with you, ensuring your plan will work for your evolving circumstances. We’re here to help you avoid unnecessary costs and attain confidence in your healthcare. At the Nesso Group, we always put your best interests first and want to take any unnecessary stress from your shoulders.


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