Ask The Medicare Specialist

Welcome to Part 7 of the series, "New to Medicare," designed to help those who will be going on Medicare for the first time soon. I want to remind readers that this series and all columns are not meant as a substitution for a one-on-one consultation with one of the licensed agents of The Health Insurance Store, nor are they written to sway your decision in enrolling in an Advantage Plan versus a Supplement or as an endorsement of any particular Advantage Plan or company.

Question: What are the most important considerations when choosing an Advantage Plan? Which plans and companies are the best?

Answer: Those going on Medicare Part B for the first time need to make sure they understand the differences between both Supplements and Advantage Plans as well as the pros and cons of each, which I have discussed during the series. Failure to educate oneself can lead to making a mistake that can have lifelong consequences. If you're a new reader, I suggest joining our Facebook Group where new columns are posted weekly. We also have four other fun and educational series found exclusively on that page. All archived columns and "New to Medicare" in its entirety can also be found on our website, www.getyourbestplan.com.

Compared to a Supplement, choosing the right Advantage Plan can be much more complicated and difficult because there are now eight companies offering them in Western PA and over 100 total plans to choose from versus only nine available Supplement plans.

And unlike Supplements where every plan of the same letter has identical benefits regardless of what company sells it, that's not the case with Advantage Plans. Premiums, co-pays, out of pocket costs, and ancillary benefits can vary quite widely among plans and companies. For example, some might have a co-pay for a 5-day or longer hospital stay of just $200 to $400 while others almost $2,000! Two people who needed the same type and amount of chemotherapy could pay thousands more or less than one another! Some plans come with thousands of dollars in "extras" while others very little.

Once someone has determined they prefer the Advantage Plan option, the most important considerations and what we want in an HMO or PPO for our clients are the following: Low premiums, but not necessarily zero dollar plans; A per stay, flat fee hospital co-pay regardless of how long the admittance is; A smaller annual Maximum Out of Pocket (MOOP) that's substantially less than the highest that Medicare allows, $9,350.; Generous ancillary benefits, the "extras" that Advantage Plans offer that neither Original Medicare nor Supplements do.

Another important consideration is the network of doctors and hospitals that are available. Not all eight companies that sell Advantage Plans in Southwestern Pennsylvania provide access to Allegheny Health Network (AHN), UPMC, Independence (Formerly Excela), and WVU. One major misconception and often poorly explained fact is a PPO does not allow people unfettered access to any provider they want. PPOs still have networks. A non-network provider must agree to accept the plan, which they sometimes don't, and many PPOs have much larger costs, possibly in the thousands, for surgeries and hospitalization when out of network services are utilized. Although not the case with most PPO plans, there are a select few that have a nationwide network that includes the majority of doctors and hospitals across the country

When it comes to Advantage Plans, paying more doesn't at all guarantee lower co-pays or out of pocket costs. In fact, most of the higher priced plans don't provide the lowest co-pays or as many or as generous ancillary benefits. We never recommend the more expensive HMOs or PPOs.

Out of the approximately 100 plans that one can choose from, only about 10 are worthy of consideration in my professional opinion and as of today, with just a few exceptions, we only advise clients to enroll in plans with three of the eight companies doing business in Western PA.

In that past five years, the most popular plans among the "Big Three," as I call the companies who own about 90% of the Western PA Advantage Plan market, have been so similar in value as far as low premiums, overall co-pay, and ancillary benefits, there was little reason for people to change. However, in 2025 the cost of Tier 3 drugs became quite different among them. Some now have a $590 deductible and/or much higher monthly costs for brand name medications while others have no or small deductibles with lower co-pays. There are even a select few plans that provide expensive diabetes drugs such as Ozempic, Trulicity, Jardiance, and others at no cost!

Don't ever choose a plan or company based on what a friend or family member has and don't call the company you had your insurance with while you or your spouse was employed! Those can be expensive mistakes!

It's also important to pay attention to any adjustments in benefits your plan may be making for the upcoming year. We send every one of our Advantage Plans clients a "recommendation letter" prior to the Medicare's Annual Enrollment Period (AEP) that starts on October 15th informing them of any significant changes they can expect and if renewing on moving to another plan or company is the wiser choice.

Reach out to us to get all your options, including Supplements, explained and presented side by side for an easy-to-follow comparison.

If you have any questions regarding this column or any other in the "New to Medicare" series or would like to set up an appointment for a no cost consultation, please call one of our offices or reach out to me personally at [email protected].