Medicare Advantage, also known as Part C of Medicare, is a plan that offers additional Medicare coverage along with Parts A & B. These are also regulated by the government and sold through private companies; however, they are subject to heavier regulation and are incorporated with HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) networks. This means that you will have to see certain doctors and receive your care in certain facilities. Other types of plans that come with Medicare Advantage are PSO (Provider Sponsored Organization), POS (Point of Service), PFFS (Private Fee-for-Service), SNP (Special Needs Plan), MSA (Medicare Medical Savings Account). Medicare Advantage plans, premiums, and benefits vary by county in each state across the country. If your income is low enough to receive Medicaid, you can receive assistance in paying your out-of-pocket costs for a Medicare Advantage Plan. Special Needs Plans also have provisions for people with certain illnesses and income levels.
Optional Prescription Drug Coverage: Medicare Part D, which is prescription drug coverage, can be purchased separately along with Original Medicare, separately along with your Original Medicare and Medicare Supplement plan, or in combination with your Medicare Advantage (Medicare Part C ) plan.
Medicare Advantage plans, also known as Medicare Part C, are private company plans that are contracted through the federal government. The companies receive fixed amounts per person to provide benefits to accompany Medicare Part A & B. You will still be responsible for paying your Part B premium (and your Part A premium if you have one) to the government. While all Medicare Advantage plans must provide you with Part A and Part B benefits, the way you receive your care will vary between companies. Some Medicare Advantage plans charge premiums, but some have $0 premiums. You may also be required to pay coinsurance and copays with your Medicare Advantage plan. Every Medicare Advantage plan has a maximum out-of-pocket limit, but they vary in amount. The 2016 cap for HMO plans is $6,850. Medicare Advantage plans are also not permitted to charge higher cost sharing amounts for services covered by Original Medicare. Most Medicare Advantage plan types are HMOs and PPOs.
Health Maintenance Organizations (HMOs): HMO plans have an established network of physicians and healthcare facilities to provide your care. They will not cover healthcare services performed outside of the network. Most HMOs will also require a referral to see a specialist.
Preferred Provider Organizations (PPOs): PPO plans also have established networks of physicians and healthcare facilities and charge fixed copays when using in-network resources. Some PPO plans allow recipients to receive care outside of the network, but recipients will be responsible for higher out-of-pocket charges.
If you are wanting Part D prescription drug coverage along with Medicare Advantage benefits, most of the time you will need to select a plan that offers Part D benefits within the plan. You can join a stand-alone plan if you are enrolled in any of the following:
Some employers or unions sponsor Medicare Advantage plans that you may be automatically enrolled into. You do have the choice to keep the plan, go to Original Medicare, or enroll into a different Medicare Advantage plan. If you choose to switch to Original Medicare or enroll into a different Medicare Advantage plan you do risk losing your employer benefits for yourself and your dependents. Be sure to speak with your employer or union before making any changes to ensure you do not lose any health benefits.
There are certain types of care that Medicare Advantage is not permitted to charge you more than Original Medicare. Some of these are dialysis, chemotherapy, and durable medical equipment. They can, however, charge you more for skilled nursing facility care, home health, and inpatient hospital services.
Most Medicare Advantage plans have networks that include only certain doctors you can see for your care. If you receive care outside of your network or do not follow the specific rules of your Medicare Advantage plan regarding how and where you receive your care, you can expect to pay more for these services.
Medicare Advantage plans can be more affordable than Original Medicare, and must cover services that Original Medicare does- but you do not have the freedom in choosing your types of care, where you get your care, or who gives you your care. All Medicare Advantage plans have different restrictions, rules, and costs. Medicare Advantage plans can work well for people who do not need a lot of care. Medicare Plans do, however, have out-of-pocket maximums that can be high but offer you protection from excessive expenses should you require a more care or expensive treatment.
Medicare Advantage plans are not permitted to charge higher copayments for some services than Original Medicare, like chemotherapy and dialysis, but they are allowed to charge higher prices for other services like inpatient hospital care. These details will be amongst the additional rules and restrictions within your plan.
Medicare Advantage will only cover services you receive within the plan’s network of doctors, pharmacies, and hospitals. If you have certain hospitals, pharmacies, or doctors you prefer to use you should check with the plan before you purchase it to ensure your services will be covered. You may also be required to go through a series of steps to get prior authorization from the plan provider before you are able to receive certain types of care, like getting referrals from your primary care physician so you can see a specialist or receive other types of drugs or services.
If your Medicare Advantage closes, you will be required to go to a new Medicare Advantage plan or switch to Original Medicare. At this time, you could purchase a Medigap policy along with your Original Medicare to supplement the gaps in coverage that Original Medicare leaves. Medigap policies can only be purchased with Original Medicare.
Most Medicare Advantage plans are HMOs (Health Maintenance Organizations) or PPOs (Preferred Provider Organizations).
Other available types are SNPs (Special Needs Plans), PSOs (Provider Sponsored Organizations), and MSAs (Medical Savings Accounts).
Each of these plans have different qualifications, rules, and restrictions. Two plans of the same type, such as two PPOs, will most likely not operate in the same nature.
It is very important to gain clarification on the specific rules for each plan. Plans may be very similar but one small difference can affect your care in very big ways. Be sure you know exactly what you are signing up for when you choose to join a Medicare Advantage plan.
If you have retiree insurance and enroll in a Medicare Advantage plan, Medicare Advantage will pay first and your retiree insurance will pay second. Some retiree benefits provide additional benefits to your Medicare Advantage plan as well as pay deductibles and copays. Retiree benefits are different for each person, but you should check with your benefits to see exactly how they may work with Medicare Advantage plans.
Each Medicare Advantage plan’s network rules are different, but there are a few characteristics they commonly share. It is very important to find out the specifics of the plan you are looking into, but some general information is below.
HMOs: Typically need a referral to see an in-network specialist; cannot see an out-of-network doctor unless it is an emergency or you have a POS (Point of Service) option that permits you to receive care out-of-network
PPOs: Do not need a referral before seeing an in-network specialist; can see out-of-network doctors at a higher out-of-pocket cost unless it is an emergency.
If you enroll in a Medicare Advantage plan instead of Original Medicare, you will use your plan membership card to show proof of coverage. You will not use the Original Medicare red, white, and blue card. You will need to present your plan card when you visit the doctor, hospital, and pharmacy if your plan has Part D prescription drug coverage.
If you enroll in a Medicare Advantage plan, they are required to notify you if they make any changes during your plan year. Changes that are sometimes made are to networks and to formularies.
Medicare Advantage plans typically have networks of doctors, hospitals, and Pharmacies that enrollees are required to use for their health care. If a provider is leaving the network, the plan is required to send written notices at least 30 days before the provider’s exit is complete.
If changes are made to your plan’s drug formulary, you do have rights depending on why the change was made. Your plan is required to update the formulary in print as well as online, and if you will be affected by the changes they are required to send you a new formulary by mail.
Medicare Advantage and Part D prescription drug plans are must provide access of coverage to recipients in the event of a public health emergency or disaster. Once the disaster or public health emergency is over, plans are allowed to resume their standard policy. The federal government is the authority to declare and end disasters and public health emergencies. In these situations, plans are required to: