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MEDICARE ADVANTAGE

Medicare Advantage

Medicare is the federal government’s health insurance program generally for people who are 65 or older, however it’s also available to certain younger people but who have disabilities and persons that have End-Stage Renal Disease (which is permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

 

Medicare Part C (Medicare Advantage Plans)

One way to receive your medicare is through a type of Medicare health plan offered by private insurance companies that are approved by Medicare and have a federal contract with the Centers for Medicare and Medicaid Services (CMS). Medicare Advantage Plans are required by the government to provide all of your Part A and Part B benefits. Medicare Advantage Plans include the following types:

  • Health Maintenance Organizations(HMO’s)
  • Preferred Provider Organizations(PPO’s)
  • Private Fee-for-Service Plans(PFFS)
  • Special Needs Plans for Dual Eligibles and Chronic Medical Conditions(SNP)
  • Medicare Medical Savings Account Plans

If you’re enrolled in a Medicare Advantage Plan you should know:

  • Most Medicare services are covered through the insurance plan that you select to enroll into.
  • Medicare services aren’t paid for by Original Medicare, they are paid for by the insurance carrier.

Most Medicare Advantage Plans package prescription drug coverage in their plans although there are some rare plans available without prescription drug coverage.

 

 

Things to Remember If You Choose to Enroll in a Part C Medicare Advantage:

 

  1. You’re still in the MedicareProgram, you Medicare is delivered through an insurance company, not Original Medicare. This is an important difference to understand.
  2. As a beneficiary you’ll still have all your Medicare rights and protections.
  3. You’ll still get complete Part A and Part B coverage through the private insurer’s health plan.
  4. Your out of pocket costs —-deductibles, copayments and coinsurance are generally lower in a Medicare Advantage Part C plan so this option may be much more cost effective for you.
  5. You can only join a Medicare Advantage Part C plan at certain times during the year. In most cases, you’re enrolled or locked in a plan for a year.
  6. You can join a Medicare Advantage Plan even if you have a pre-existing medical conditions except for End-Stage Renal Disease (ESRD). If you have ESRD, you’ll most likely need to get your Medicare benefits from Original Medicare unless a Medicare Advantage ESRD Special Needs Plan is available in your area. Please check with us to find out what plans are available in your zipcode.
  7. You can check with the Medicare Advantage plan before you enroll to find out if it’s covered and what your costs may be.
  8. Following plan rules, like getting a referral to see a specialist in the plan’s network is generally required in order to keep your costs lower. Check with the insurance plan’s evidence of coverage documents to get further details.
  9. Go to a physician, other health care provider, facility, or durable medical equipment supplier that belongs to the insurance plan’s provider network, so your services are covered and your costs are less. In most cases, this applies to Medicare Advantage plans that are Health Maintenance Organization(HMOs) and Preferred Provider Organization(PPOs).
  10. Medical providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network at any point in time during the year. If this should happen, you’ll need to choose a new doctor..
  11. If you choose to join a clinical research study some costs may be covered by your insurance plan. Call your Medicare Advantage plan for more information.
  12. Medicare Advantage Plans cannot charge anymore than Original Medicare for certain services like chemotherapy for cancer, kidney dialysis, and skilled nursing facility care(SNF).
  13. Medicare Advantage Plans (Part C) have an annual limit on your out of pocket costs for medical services, this is called the maximum out of pocket limit. Once you reach your maximum limit, you’ll pay $0 for covered services. Each insurance carrier sets the maximum out of pocket limit for their plan, each insurance plan can have a different limit, and the limit can change every year. You should consider what the maximum out of pocket limit is when choosing a plan.
  14. If a Medicare Advantage plan decides to stop participating in Medicare, you’ll be notified that you have to join a different Medicare plan or return to Original Medicare.

 

 

What to Consider When Choosing A Medicare Plan

 Costs:

How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Is there a yearly limit on what you could pay out-of pocket for medical services? Make sure you understand any coverage rules that may affect your costs.

 

What are the Costs in Medicare Advantage?

Medicare Advantage Part C Plans have an annual limit on your out-of-pocket costs. If you enroll in a Medicare Advantage Plan, once you reach a set maximum  limit, you’ll pay $0 for covered services for the rest of the year. This makes a Medicare Advantage plan an enticing option that may be more cost effective for you.

Note

If you’re in a Medicare Advantage Part C plan, review the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC) your plan sends you each year, usually in the fall. The EOC gives you details about what the plan covers, how much you pay, and more. The ANOC includes any changes in coverage, costs, or service area effective in January. If you don’t receive an EOC or ANOC, be sure to contact your insurance plan as soon as possible. Get your plan’s contact information from your member ID card or contact us if you need assistance finding contact information for the insurance carrier.

COVERAGE

How well does the Medicare Advantage plan cover the services you’ll need?

 

Coverage in a Medicare Advantage Plan            

Plans must cover all of the services that Original Medicare covers. Many plans offer benefits that Original Medicare doesn’t cover like vision, hearing, or dental.

If you have other types of health or prescription drug coverage, make sure you understand how that coverage works with Medicare. If you have employment-related coverage, or get your health care from an Indian Health or Tribal Health Program, talk to your benefitsadministrator or insurer before making any changes.

 

Supplemental Coverage In A Medicare Advantage

Because Original Medicare doesn’t cover all your deductibles, copayments and coinsurance it may be more cost effective for you to join a Medicare Advantage Plan because your cost sharing is lower (or included). And, many Medicare Advantage plans offer vision, hearing, and dental. You cannot use (and can’t be sold) a Medicare Supplemental insurance policy if you’re in a Medicare Advantage Plan.

Doctor and Hospital Choice

Do your doctors accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network ? Do you need to get referrals?

 

Doctor’s and Hospital Choices in a Medicare Advantage Part C Network

You may need to use health care providers who participate in the plan’s network. If so, find out how close the network’s doctor or pharmacies are to your home. Some plans offer out-of-network coverage.

 

Quality of Care

Are you satisfied with your medical care? The quality of care and services offered by plans and other health care providers can vary. How have Medicare and other people with Medicare rated your health and drug plan’s care and services?

Travel

Will the plan cover you if you travel to another state or outside the U.S.?

 

Travel Coverage in Medicare Advantage Plans

Medicare Advantage Plans (Part C) usually don’t cover care you get outside of the U.S.

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