Medicare Advantage Plans: Is Your Heart Surgery Covered?

Medicare Advantage Plans: Is Your Heart Surgery Covered?
Medicare Advantage Plan

Medicare Advantage plans are health plan options that are part of the Medicare program, but are offered by private health insurance companies. They provide an alternative way to receive Medicare benefits compared to Original Medicare, which is managed directly by the federal government.

The key differences between Medicare Advantage and Original Medicare include:

Privately administered plans - Medicare Advantage plans are administered by private insurance companies, whereas Original Medicare is managed by the federal government.

Bundled benefits - Medicare Advantage plans combine Part A, Part B, and often Part D benefits into a single plan with one monthly premium. With Original Medicare, you need to get Parts A and B, and a separate Part D plan for drug coverage.

Extra benefits - Medicare Advantage plans often include additional benefits not provided by Original Medicare like dental, vision, hearing, and more.

Provider networks - Medicare Advantage plans have provider networks you must use to get care covered at in-network costs. Original Medicare allows you to see any provider who accepts Medicare nationwide.

So in summary, Medicare Advantage provides an alternative way to get your Medicare benefits from private insurers with bundled coverage, extra benefits, and provider networks, while Original Medicare is managed directly by the government with standard benefits and the freedom to see any Medicare provider.

Medicare Advantage Plan Types


Medicare Advantage plans come in different types, with the main options being HMO, PPO, and PFFS plans. Understanding the key differences can help you choose the right plan for your needs.


HMO Plans


HMO stands for Health Maintenance Organization. This type of Medicare Advantage plan requires you to get care from doctors and facilities within the plan's network, except in emergencies. You may need referrals from your primary care doctor before seeing specialists.



- Tend to have lower premiums and out-of-pocket costs

- Care is managed and coordinated through your primary care doctor



- Limited provider network 

- Need referrals for specialists

- No coverage for out-of-network care except emergencies


PPO Plans


PPO stands for Preferred Provider Organization. This type of Medicare Advantage plan allows you to see any doctor or facility that accepts Medicare, without referrals. Costs are lower when using in-network providers.



- Freedom to choose any Medicare provider

- Out-of-network care allowed but with higher costs  

- No referrals needed for specialists



- Monthly premiums tend to be higher

- Out-of-network care costs more


PFFS Plans


PFFS stands for Private Fee-For-Service. This is a less common type of Medicare Advantage plan that works similar to original Medicare - you can choose any provider without referrals as long as they accept the plan's payment terms.



- Freedom to choose any Medicare provider nationally

- No network limitations



- Providers can choose not to accept PFFS plans

- Some plans have a partial network

- Tend to have higher costs


Understanding the differences between these main Medicare Advantage plan types allows you to choose the right balance of flexibility and costs.


Medicare Advantage Benefits 


Medicare Advantage plans cover all of the same services that Original Medicare does, including:


- Doctor visits for illness and preventive care

- Hospitalization 

- Emergency care

- Urgently needed care

- Lab tests

- X-rays 

- MRIs, CT scans, EKGs, etc.

- Ambulance transportation

- Mental health services

- Skilled nursing facility care 

- Durable medical equipment

- Prosthetic devices 

- Diabetes supplies

- Some even cover vision, dental, hearing aids, fitness benefits, and more


The key advantage of Medicare Advantage plans is that they also include Medicare Part D prescription drug coverage. With a Medicare Advantage Plan, you get all your Part A, Part B, and Part D benefits together in one coordinated plan. This can make it easier to understand what is covered and get the most value from your Medicare benefits.


For heart surgery patients specifically, having Part A, Part B, and Part D together under a Medicare Advantage plan ensures your hospitalization, doctor visits, tests, and prescription medications before and after surgery will all be covered under one plan. This can help minimize out-of-pocket costs and provide coordinated care.


Choosing a Medicare Advantage Plan


When it comes time to choose a Medicare Advantage plan, you'll want to consider your specific healthcare needs and budget. The best place to start is by using the “Find an affordable Medicare Service Plan '' on This tool allows you to enter your zip code and see all of the Medicare Advantage plans available in your area. You can compare the costs, benefits, and quality ratings of each plan side-by-side.


Here are some key things to consider when choosing a Medicare Advantage plan:


Your total out-of-pocket costs - Take into account the plan's premiums, deductibles, copays, and maximum out-of-pocket limits. Make sure your total costs fit within your budget.

Covered services - Check that the plan covers all the healthcare services you need, especially any upcoming surgeries or procedures. Make sure your doctors and preferred hospitals are in-network.

Prescription drug coverage - Most Medicare Advantage plans include prescription drug coverage. Review the plan's formulary to ensure it covers your medications.

Quality ratings - Medicare rates plans on a 5-star scale. Opt for a plan with 4 stars or higher.

Travel coverage - If you travel frequently, look for a plan that has national coverage or coverage in the regions you visit.

Fitness programs - Many plans offer gym memberships and other health programs as extra benefits.

By comparing plans side-by-side on Medicare's website, you can find the Medicare Advantage plan that provides the optimal balance of cost, coverage, and quality for your needs. Make sure to review plan details carefully before enrolling.

Enrolling in Medicare Advantage

Medicare Advantage has specific enrollment periods you need to be aware of. This ensures you enroll at the right time to get the coverage you need without penalties.


Initial Enrollment Period

When you first become eligible for Medicare, you have a 7-month initial enrollment period to sign up for Medicare Advantage. This includes:

- The 3 months before you turn 65 

- The month you turn 65

- The 3 months after you turn 65

If you enroll in Medicare Advantage during your initial enrollment period, you can choose between Medicare Advantage plans with or without prescription drug coverage.

If you're under 65 and become eligible for Medicare due to disability, your initial enrollment period depends on the date your disability is approved. 

It's important to enroll on time during your initial enrollment period. If you don't, you may have to wait until the next annual enrollment period and you may pay a late enrollment penalty.


Annual Election Period 


If you want to make changes to your Medicare Advantage coverage, you can do so during the annual election period from October 15 to December 7 each year. During this time you can:

- Switch from Original Medicare to Medicare Advantage 

- Switch from one Medicare Advantage plan to another

- Drop your Medicare Advantage plan and return to Original Medicare


Changes made during the annual election period take effect January 1 of the following year. This gives you an opportunity each fall to evaluate your coverage and make adjustments for the following year.


The annual election period is critical for enrolling in or changing your Medicare Advantage plan. Carefully consider your options during this time frame to get the right coverage.


Using Medicare Advantage for Heart Surgery


Heart surgery can be a major medical event that involves significant costs. Having the right Medicare Advantage plan in place is crucial to help manage expenses and coordinate care. When selecting a Medicare Advantage plan for upcoming heart surgery, there are some important factors to consider:


Plan Selection Advice


- Look for a plan with a large network of cardiologists and heart surgery centers. This gives you the most options for high-quality care.


- Prioritize plans with low copays and deductibles for surgery and hospitalization. Heart surgery often requires a multi-day hospital stay, so you want to minimize out-of-pocket costs. 


- Consider plans with transportation benefits to appointments or a meals benefit following surgery. These extra benefits can make recovery easier.


- Choose a plan with a cap on your maximum out-of-pocket costs for the year. Heart surgery can be expensive, so limiting your total costs is ideal.


Coordinating Benefits  


- Contact the plan to understand pre-authorization requirements for surgery. Most plans require approval in advance.


- Ask about case management services. See if a nurse or coordinator can help schedule surgery and manage follow-up care. 


- Understand the rehabilitation therapy benefits offered. Many plans include a limited number of physical therapy visits after surgery.


- Check if in-home recovery benefits are offered. Some plans provide home health aides or nursing visits after discharge.


Medicare Advantage Ratings


Medicare Advantage plans are rated on a 5-star rating system by Medicare each year. These star ratings are based on measures of the plan's quality and performance. The ratings help consumers compare plans when choosing a Medicare Advantage plan to enroll in.


The star ratings are in several categories:


- Staying healthy - screenings, tests, vaccines 

- Managing chronic conditions

- Member experience with the health plan

- Member complaints and changes in the health plan's performance

- Health plan customer service

- Drug plan customer service


Plans can receive between 1 and 5 stars overall. 5 stars is considered excellent, while 1 star is poor. The higher the star rating, the higher quality the Medicare Advantage plan.


When comparing plans, be sure to look at the overall star rating and the ratings in specific categories that matter most to you. This will help you find a high quality Medicare Advantage plan that fits your healthcare needs and priorities. Choosing a 5 star Medicare Advantage plan can give you the best access to high quality care and extra benefits.


Frequently Asked Questions


Can I get prescription drug coverage with Medicare Advantage?


Yes, most Medicare Advantage plans include Part D prescription drug coverage. This is built into the plan so you don't have to purchase a separate standalone Part D plan. When comparing plans, pay close attention to the prescription drug benefits offered.


What doctors and hospitals can I use with a Medicare Advantage plan? 


Medicare Advantage plans have network providers you must use to get the highest level of coverage. Check to see if your preferred doctors, specialists, hospitals, and pharmacies are in-network before enrolling in a plan. Most plans have online provider lookup tools to easily search for participating providers.


Am I still in the Medicare program if I join a Medicare Advantage plan?


Yes, Medicare Advantage plans are part of the Medicare program offered by private insurance companies. You're still in Medicare if you join a Medicare Advantage plan, which provides the same Part A and Part B benefits traditional Medicare offers.


Can I get Medigap to supplement my Medicare Advantage plan?


No, you cannot purchase a Medigap policy to cover cost-sharing with an Medicare Advantage plan. Medigap is only available to supplement Original Medicare. However, Medicare Advantage plans have annual out-of-pocket maximums that limit your costs for the year.


When can I make changes to my Medicare Advantage plan?


You can make changes to your Medicare Advantage plan during Medicare's annual open enrollment from October 15 to December 7 each year. This is the time when you can switch Medicare Advantage plans or drop your plan and go back to Original Medicare. There are also special enrollment periods for certain situations.


How do I disenroll from a Medicare Advantage plan and switch back to Original Medicare? 


To disenroll, call the plan or Medicare to process the disenrollment. You'll automatically be returned to Original Medicare when your plan's coverage ends. You'll have the option to purchase a Part D plan and Medigap policy if switching back to Original Medicare.

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