Medicare Advantage Plans

Medicare Advantage plans allow you to get all the coverage Original Medicare (Parts A and B) offers, plus additional benefits and services all in one single plan.

What Is A Medicare Advantage Plan?

Medicare Advantage plans (also known as Medicare Part C) are offered by private insurance companies and approved by Medicare. They allow you to get all the coverage Original Medicare (Parts A and B) offers, plus additional benefits and services all in one single plan. Many Medicare Advantage plans may also include prescription drug coverage (Part D), often for no additional premium. It is important to remember, that if you join a Medicare Advantage plan, you will still have Medicare. You just will get your coverage from your Medicare Advantage Plan, rather than Original Medicare.

I Heard Medicare Advantage Plans Include Extra Benefits, Is That True?

The answer is most likely yes, as benefits differ by plan and frankly by state. One plan offered in Texas may not have the same extra benefits as one in Florida or California but in general, many Medicare Advantage plans include routine vision, hearing, and dental care. Some also will include transportation benefits, telemedicine virtual visits like Teladoc, a monthly allowance for over-the-counter items, and fitness memberships such as Silver Sneakers, that will give you complimentary access to local in-network facilities, such as Gold’s Gym in San Antonio, Texas for example. These extra’s are unique to Medicare Advantage plans, as Original Medicare will not cover them.

How Do I Become Eligible For Medicare Advantage Plans?

You’re eligible for a Medicare Advantage plan if you are enrolled in Original Medicare Parts A and B, live in the plan’s service area, and you do not have end-stage renal disease. So be sure to double-check that a plan is available in your local area, whether that is San Antonio, Texas, Pensacola, Florida, or even Los Angeles, California. It is important to remember, that you will continue to pay your Part B premium, in addition to your plan’s premium (if there is one) for Medicare Advantage plans.

When Can I Sign Up For A Medicare Advantage Plan?

You can sign up for a Medicare Advantage plan at least once a year, typically during your Initial Enrollment Period (IEP) or Annual Enrollment Period (AEP).

Initial Enrollment Period- 

This period begins three months before, during your birthday month and ends three months after you either: turn 65 or become eligible for Medicare.

Annual Enrollment Period-

This is the time during the year you can choose or change your Medicare Advantage or Part D plan. This period runs from October 15th through December 7th each year. Your enrollment during this period becomes effective January 1st of the following year.

Special Election Period-

If you qualify due to certain reasons, such as having both Medicare and Medicaid or you are receiving “Extra Help” from the government with your Part D drugs, you are allowed to sign up at any point during the year. For more information on what qualifies for this election period, click here.

Open Enrollment Period-

This period allows you to switch from one Medicare Advantage plan to another, disenroll from a Medicare Advantage plan and go back to Original Medicare. If you choose to do so, you can then join a Medicare Prescription Drug plan. You cannot however, go from Original Medicare to a Medicare Advantage plan/Prescription Drug plan. This period runs from January 1st through March 31st each year.

What If I Change My Mind And Want To Disenroll From A Medicare Advantage Plan?

No problem. You would do this in the Medicare Advantage Disenrollment Period, which runs from January 1st through February 14th. During this time, you can return to Original Medicare or enroll in a stand-alone Medicare prescription drug plan. Keep in mind, you may not switch to another Medicare Advantage plan during this time.

Do I Need To Enroll Each Year?

This is a question we get asked often here in San Antonio, Texas, and the short answer is that your plan automatically renews each year as long as you pay the premium and the plan is available in your service area. You do not have to do anything to your coverage, but make sure that the plan is meeting your ongoing needs.

Types of Medicare Advantage Plans:

Health Maintenance Organization (HMO) Plans-

HMO plans require you to seek care from providers in your network. Many of these plans will require you to get a referral from your primary care physician to see a specialist.

Preferred Provider Organization (PPO) Plans-

PPO plans typically don’t require a referral to see a specialist and allow you to see providers outside the network without having to pay the entire cost yourself.

Point Of Service (POS) Plans-

A type of HMO plan that allows you to see doctors and hospitals outside the network for some covered services, usually for a higher co-pay or co-insurance.

Special Needs Plans (SNP’s)-

SNP’s are designed for people with a range of special needs, including those with chronic diseases, nursing home residents, and people who are eligible for both Medicare and Medicaid.

Private Fee-For-Service (PFFS) Plans-

PFFS plans allow enrollees to see any providers in the U.S. who accept Medicare’s payment terms and conditions.

Medical Savings Account (MSA) Plans-

MSA plans combine Medicare Advantage plan coverage with a special savings account you can use to pay for covered expenses tax-free.

How Does Cost Sharing Work With Medicare Advantage Plans?

Most Medicare Advantage plans utilize a combination of deductibles, co-insurance’s, and co-pays to share the costs of your care with you. These cost-sharing arrangements will usually apply to all of the services the plan covers, such as hospital stays, doctor visits, drug coverage if you have it, and so forth.

Is There A Limit To What I Can Be Asked To Pay Out-Of-Pocket?

In short, yes. Limits on your cost sharing is another way that Medicare Advantage plans differ from Original Medicare (Parts A and B), as for example, you may have a $3,400 out-of-pocket maximum with Medicare Advantage and on Original Medicare (Parts A and B), you do not have an out-of-pocket maximum. So if someone had a massive heart attack, and the bill was $50,000 dollars, you would only pay up to the $3,400 on Medicare Advantage plans and with Original Medicare (Parts A and B), you would pay 20%, all the way to $50,000! Sounds like a financial disaster in the making, right? We often run into people here in San Antonio, Texas and further out in Florida and California who are very surprised by this factor and it truly is an eye opener to say the least. 

What Are The Payment Stages If My Medicare Advantage Plan Has Prescription Drug Coverage?

Stage #1- Deducible Stage:

During this stage, if your plan has a deductible, you usually pay the full cost of your drugs up to the deductible amount. This in general, applies to drugs on tiers 3, 4, and 5. Once you reach the deductible amount, you pay a co-payment or co-insurance in the initial coverage stage.

Stage #2- Initial Coverage Stage: 

During this stage, the plan pays its share of the cost and you pay a co-payment or co-insurance (your share of the cost) for each prescription you fill until your total drug costs reach $3,820. Once you reach $3,820, you enter the coverage gap or “donut hole”.

Stage #3- Coverage Gap Stage:

During this stage, you receive limited coverage on certain drugs. You’ll also get a discount on brand-name drugs and generic drugs. This stage continues until your yearly out-of-pocket drug costs reach $5,100. Once your yearly out-of-pocket costs reach $5,100, you move to catastrophic coverage.

Stage #4- Catastrophic Coverage Stage: 

In this stage, you pay only a small co-payment or co-insurance amount for each prescription you fill.

What Is A Summary Of Benefits?

A summary of what the plan covers and what you will pay. It does not list every service that is covered or list every limitation or exclusion.

What Is A Evidence Of Coverage?

The plan evidence of coverage provides you with a complete list of services that are covered. You can often find this on your plan’s website, or by calling your plan’s customer service number for a copy to be sent to you.

What Are Star Ratings?

Star ratings are a way for consumers to compare the relative quality of care of Medicare Advantage plans. The Centers for Medicare & Medicaid Services (CMS) issues the ratings based on:

  • Administrative Results
  • Clinical Outcomes
  • Plan Member Surveys

Every Medicare Advantage plans receives star ratings from one star (lowest) to five stars (highest). CMS also issues an overall star rating for each plan. It is based on performance across certain measures such as accessing health plan customer service. No matter if you are in San Antonio, Texas, Pensacola, Florida or even Los Angeles, California, always have your agent review the star ratings of an Medicare Advantage plan with you, before making your selection. 

Key Terms:


The fixed amount you pay your health insurance or plan for Medicare coverage. You may pay your premium to Medicare, to a private insurance company, or both, depending on your coverage. Most premiums are charged monthly.


A set amount you pay out of pocket for covered services each year before your plan begins to pay.


The costs that you and the health insurance plan pay are split on a percentage basis. For example, you may pay 20% of the total allowed costs of a service and the plan would pay the remaining 80%.


The fixed amount you pay at the time you receive a covered service. For example, you might pay $20 when you visit the doctor or $5 when you fill a prescription.

Out-Of-Pocket Maximum-

The maximum amount you pay during a policy period (usually a year). This amount does not include your premium or the cost of any services that are not covered by your plan. After you reach your out-of-pocket maximum, your plan pays 100% of the allowed amount of covered services for the rest of the policy period.


A formulary is a list of drugs your plan covers. Generally, the lower the tier, the less you’ll pay for your prescription drugs.

Prior Authorization- 

The process used to determine if a service or prescription drug is covered by your plan. If prior authorization is required, you and/or your doctor must contact the plan before you get the service or fill your prescription. Your doctor may need to show the service or drug is medically necessary for your plan to cover it.

Total Drug Cost-

The amount of money both you and the plan spend on a covered prescription drug.

Please refer to the 2020 Centers for Medicare and Medicaid Services (CMS) booklet for a complete outline of the Medicare Advantage program.

Did You Know?: As you will see below, more than 17 million seniors in 2016, counted on Medicare Advantage plans for all of their health care needs. Reach out to us today if you reside in the greater San Antonio, Texas area, or even farther out in Texas, California or Florida respectively. Allow us the opportunity to find a plan that suits your individual needs, such as a plan that includes a fitness benefit like Silver Sneakers. We work with all the top carriers, to empower you to fully compare plan choices.

The Harrin Group offers free, comparative quotes on Medicare Advantage plans from multiple insurance carriers so you can get the best possible rate.

Want to see how much we can save you? Just request a quote to find out.

Sources: Teladoc, Silver Sneakers, The Social Security Administration,, Better Medicare Alliance