How to Choose the Right Medicare Advantage Plan

3 Key Factors We Use to Evaluate Medicare Advantage Plans with Our Clients

When it comes to choosing the right Medicare Advantage plan, we understand how overwhelming it can feel. With over 20 years of experience working with these plans, we’ve noticed that—regardless of the insurer or location—all Medicare Advantage plans generally boil down to three common categories. Once you understand those, along with a few core Medicare terms, you’ll be in a strong position to make an informed decision year after year, without second-guessing your choice.

Let’s walk through the key steps we take with clients to help them find the plan that supports their healthcare and financial needs.

Step 1: Understand Medicare’s “Language”

Before we even look at plans, we always take a moment to review Medicare terminology with our clients. Medicare has its own set of acronyms that can be confusing. Here are the core terms we make sure you understand:

• HMO (Health Maintenance Organization): You’ll generally need to stick to a defined network of doctors and may require referrals to see specialists.
• HMO-POS (Point of Service): A more flexible version of the HMO; you can see specialists without referrals, but still within the plan’s network.
• PPO (Preferred Provider Organization): Offers access to both in- and out-of-network providers. You’ll save money staying in-network, but have the flexibility to go outside of it.
• C-SNP (Chronic Special Needs Plan): Designed for people with certain chronic conditions such as diabetes, heart disease, or COPD.
• D-SNP (Dual Special Needs Plan): For those eligible for both Medicare and Medicaid. These plans are tailored to coordinate your benefits across both programs.

We also clarify how Medicaid (or Medi-Cal in states like California) works and what it means to qualify for a D-SNP plan. Once you’re confident in the terminology, we can evaluate plan options in a much more meaningful way.

Step 2: Understand the Three Plan Categories

All Medicare Advantage plans fall into one of three strategic categories. Each has distinct pros and cons, which we weigh carefully with each client.

New Medicare Advantage Plans in Your Area

These include both small, local insurers and big national names like Aetna or UnitedHealthcare that are newer to your specific county.

Pros:

• Often offer very low co-pays and low maximum out-of-pocket limits—sometimes as low as $500.
• Tend to include a wide range of perks: dental, vision, gym memberships, groceries, transportation, and even pet services.
• $0 monthly premium is standard.

Cons:

• Smaller doctor and hospital networks—and those networks may still be developing.
• Customer service, billing, and claims systems may still have some “kinks.”
• Some of these plans overextend financially and exit the market after a few years.

Established Medicare Advantage Plans

These are long-standing Medicare Advantage plans that have been serving your area for years and have built strong provider networks.

Pros:

• Larger, more stable doctor and hospital networks.
• Reliable customer support and smoother billing systems.

Cons:

• Fewer extras and perks. For example, they may only cover preventive dental care rather than full coverage.
• Co-pays may not be as low as those in newer plans.

One-Stop Shop Medicare Advantage Plans

These are typically associated with healthcare systems like Kaiser or Sutter, where your primary care doctor, specialists, labs, and pharmacy are all under one roof.

Pros:

• Convenience—everything is centralized in one location, making care easier to manage.
• Often part of large, reputable health systems

Cons:

• Higher monthly premiums, often ranging from $30 to $90
• Typically, fewer auxiliary benefits are available, and you may need to purchase dental/vision separately.
• Higher co-pays in some cases.

Step 3: Be Cautious When Switching from Medicare Advantage to Medigap

Before enrolling in a Medicare Advantage plan, we also help clients understand what happens if they ever want to switch back to Original Medicare with a Medigap Supplement. Most people don’t realize that:

• You may not be guaranteed Medigap approval if you try to switch later.
• There are three different Medicare enrollment windows, each with its own rules that affect your options.

For these reasons, we work closely with clients to weigh not only today’s needs but also how a plan fits into their long-term healthcare strategy.

Final Thoughts

Choosing a Medicare Advantage plan is about much more than premiums or perks. It’s about finding the right balance of cost, network, coverage, and convenience for your needs.

At our KCIIS, we walk clients through these three categories—New  Medicare plans, established Medicare plans, and one-stop shop Medicare plans—and help compare side-by-side based on what matters most to you. That way, you can enroll confidently and avoid costly surprises down the road.

If you’re considering a change to your Medicare plan, let’s schedule a time to talk. We’ll help you make a decision that’s financially sound, medically practical, and tailored to your lifestyle.