Medicare Advantage in Baltimore City, explained plainly

Let's bust a myth first. The mailers and TV ads say a Medicare Advantage plan is "free Medicare with extra perks." The truth is more useful than that. An Advantage plan is a bundle: one private plan that replaces Original Medicare, with its own doctors, its own rules and its own yearly costs. For the right person it works very well. For the wrong person it causes headaches. Our job is to tell you which is which.

Medicare is all we do, and we have been serving seniors since 2011. This guide covers what Baltimore City residents should look at before choosing, from hospital systems to the fine print.

What a Medicare Advantage plan is

You still have Medicare. You keep paying your Part B premium, and you still use a Medicare card to get care. The difference is that a private insurance company runs your benefits. Most plans include Part D drug coverage in the same bundle, and many add dental, vision, hearing and fitness benefits that Original Medicare does not include.

The tradeoff is that you agree to stay within the plan's rules. Most Advantage plans use a network of doctors and hospitals, and some require a referral to see a specialist or prior approval for certain services. Think of it as pay-as-you-go: you pay a copay when you use care, instead of paying a yearly deductible and then sharing costs.

Why Baltimore City is its own shopping area

Advantage plans are sold county by county. Baltimore became an independent city in 1851, so it sits outside every county, even though Baltimore County wraps around most of it. That matters. A plan your cousin in Towson loves may not be offered in the city at all, or it may come with a different network and different benefits.

It also matters because so much of your care here runs through a few large hospital systems. The Johns Hopkins Hospital serves East Baltimore, Sinai Hospital sits in Northwest Baltimore, and Mercy Medical Center is downtown. A plan can include one of them, all of them, or none, and the list can change from one January to the next. Network participation varies by plan, so always check your own doctors, hospital and pharmacy before you enroll. Our local health resources page lists these hospitals, plus urgent care and adult day care options.

Extra benefits to compare

Extra benefits are where plans differ the most. Depending on the plan, you may see:

• Dental and vision: exams, cleanings, glasses allowances. Limits apply.
• Hearing: exams and hearing aid allowances.
• Fitness programs: gym memberships or at-home programs.
• Rides to appointments: a set number of trips per year on some plans.
• Over-the-counter allowance: a card or catalog for health items on some plans.

Benefits vary by plan and change every year. A rich list of extras does not help if your doctor is not in the network, so we always start with your doctors and prescriptions, and look at extras second.

Your yearly cost limit, explained

Every Advantage plan has a yearly maximum out of pocket for covered services. Once you reach it, the plan pays 100% of covered in-network care for the rest of the year. Original Medicare has no such limit on its own, which is why people with Original Medicare often add a Supplement. Your monthly premium, and what you pay for prescriptions in some cases, may not count toward the limit, so read how each plan defines it.

Here is a simple way to see the difference between the two paths:

Neither path is better for everyone. We compare tradeoffs and let your doctors, medications and budget decide.

Annual enrollment checklist

Every year the Annual Enrollment Period runs October 15 through December 7, with new coverage starting January 1. If you are already in an Advantage plan, you also have an Open Enrollment Period from January 1 through March 31 to make one change. Here is a calm way to use that time:

1. Read the Annual Notice of Change your plan mailed you. Look for changes to your doctors, drugs and copays.
2. Write down your doctors, your hospital and every medication.
3. Check your pharmacy against each plan you are considering.
4. Compare the maximum out of pocket, not just the monthly premium.
5. Call us before you cancel anything, so you do not end up with a gap in coverage.

Saying "no one told me" about a Medicare deadline will not undo a missed one, so it is never too early to plan.

Medicare Advantage questions we hear in Baltimore

Final thoughts

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