As the new year begins, many Medicare beneficiaries are starting fresh with new coverage. If you switched to a Medicare Advantage plan during the Annual Enrollment Period, your new benefits took effect on January 1. While Medicare Advantage plans can offer great value and convenience, they can also be a little confusing at first.
At Carolina Senior Benefits, we want to help you feel confident and prepared as you get used to your new plan. Here’s a simple guide to understanding your coverage and getting the most out of your Medicare Advantage benefits this year.
Review Your Plan Materials
When your plan went into effect, you should have received a Summary of Benefits and Evidence of Coverage (EOC) from your insurance company. These documents explain exactly what’s covered and what your costs will be.
Take some time to read through them carefully, paying close attention to:
- Monthly premium and deductible: Know what you’ll pay before your plan starts covering certain services.
- Maximum out-of-pocket limit: Once you reach this amount, your plan pays 100% of covered services for the rest of the year.
- Copays and coinsurance: Understand what you’ll owe for doctor visits, hospital stays, or outpatient care.
- Included extras: Most Medicare Advantage plans offer additional benefits such as dental, vision, hearing, fitness programs, and more.
Keep all your plan materials in one place so you can easily reference them throughout the year.
Make Sure Your Providers Are In-Network
One of the biggest differences between Original Medicare and Medicare Advantage is that Advantage plans typically have provider networks. Most plans are either HMOs or PPOs, and knowing which type you have is crucial.
- HMO (Health Maintenance Organization): You’ll generally need to see in-network providers and get referrals from your primary care doctor for specialist visits.
- PPO (Preferred Provider Organization): You can see both in-network and out-of-network providers, but you’ll usually pay more if you go outside the network.
To confirm your doctors and hospitals are in-network:
- Visit your plan’s website and use their provider search tool.
- Call your provider’s office to verify participation.
- Contact your plan’s customer service for help finding nearby network providers.
Staying in-network can save you a significant amount of money and help you avoid unexpected bills.
Set Up an Appointment with Your Primary Care Provider
Once your coverage is active, schedule a check-up or annual wellness visit with your primary care physician (PCP). If you’re in a new plan, this visit can help you start the year on the right foot.
During this appointment, you can:
- Review your medical history and current prescriptions
- Discuss preventive screenings or vaccinations
- Ask about referrals to specialists, if needed
- Learn about wellness resources your plan might offer
Preventive services ( like flu shots, screenings, and annual checkups) are often covered at no additional cost under Medicare Advantage. Building a good relationship with your PCP ensures you get the most from your plan and stay proactive about your health.
Learn How Your Prescription Coverage Works
Most Medicare Advantage plans include Part D prescription drug coverage, but the details can vary from plan to plan. Understanding how your drug benefits work can help you save money and avoid surprises.
Here’s what to do:
- Review your plan’s formulary (drug list). Make sure your medications are covered and check which “tier” each one falls under. Drugs in lower tiers usually cost less.
- Confirm your preferred pharmacy. Some pharmacies are “preferred,” meaning they offer lower copays.
- Explore mail-order options. Many plans let you get a 90-day supply of maintenance medications by mail, often at a discounted price.
- Ask about alternatives. If one of your medications isn’t covered or has a high copay, your doctor may be able to prescribe a similar, lower-cost option.
Even if you’ve had Part D coverage before, your new Medicare Advantage plan may have different rules. Reviewing these details early will help prevent gaps in coverage or unnecessary expenses.
Take Advantage of Extra Benefits
One of the best parts of Medicare Advantage is the extra coverage that comes with many plans. These benefits go beyond Original Medicare and can improve both your health and quality of life.
Common extras include:
- Dental coverage: Cleanings, exams, and sometimes dentures or crowns.
- Vision benefits: Eye exams, glasses, or contact lenses.
- Hearing coverage: Hearing exams and discounted hearing aids.
- Over-the-counter (OTC) allowances: A monthly or quarterly benefit for items like vitamins, bandages, or cold medicine.
- Transportation: Rides to and from medical appointments.
- Fitness memberships: Programs like SilverSneakers® or Renew Active®.
- Telehealth services: Virtual visits for primary care or mental health.
Don’t let these benefits go unused; you’ve already paid for them as part of your plan. Check your plan materials or online portal to see what’s included and how to access it.
Many beneficiaries are surprised by how much value these additional perks can add when used consistently throughout the year.
Set Up Your Online Account or Mobile App
Nearly all Medicare Advantage carriers now offer online portals or mobile apps that make managing your plan easier. Once you create an account, you can:
- View your ID card and coverage details
- Track claims and spending
- Order OTC items or mail-order prescriptions
- Find in-network doctors and pharmacies
- Schedule telehealth appointments
Using your plan’s online tools is one of the simplest ways to stay organized and in control of your healthcare. If you prefer, many plans also have phone-based support to help you access these resources.
Understand Your Costs and Coverage Rules
It’s helpful to know how your plan handles costs for different services. Every Medicare Advantage plan includes:
- Copays: Fixed amounts for certain visits (for example, $20 for a primary care visit).
- Coinsurance: A percentage of the cost you pay for some services, such as hospital stays.
- Maximum out-of-pocket limit: Once you reach this limit, your plan covers 100% of approved medical expenses for the rest of the year.
You should also familiarize yourself with rules like prior authorization, which means your plan must approve certain procedures or prescriptions before they’re covered.
By keeping good records and reviewing your Explanation of Benefits (EOB) statements, you’ll stay aware of your spending and coverage progress.
Know Who to Contact for Help
If you have questions or encounter any issues, don’t hesitate to reach out for assistance.
- Your plan’s member services: For claims, billing, or benefit details.
- Your provider’s office: For referral or appointment questions.
- Carolina Senior Benefits: For personalized help understanding your plan, comparing costs, or resolving coverage concerns.
Starting a new Medicare Advantage plan can take some getting used to, but with the right information, you can take full advantage of everything it offers. Review your plan materials, confirm your providers, understand your costs, and use those valuable extra benefits.
At Carolina Senior Benefits, our mission is to help Medicare beneficiaries make informed decisions and get the most from their coverage. If you have questions about your new Medicare Advantage plan or need help understanding your benefits, we’re just a phone call away.
