Medicare Advantage plans (also known as Medicare Part C) provide Part A (hospital), Part B (medical) and typically Part D (drug) coverage. To enroll in a Medicare Advantage Plan, you must be enrolled in Original Medicare Part A and Part B.
Medicare Advantage plans are part of the federal Medicare program and offered through approved private insurers, such as Cigna-HealthSpring, to provide extra coverage. There are various types of Medicare Advantage plans, such as HMO, PPO and Private Fee-for-Service plans.
With a Medicare Advantage plan, you may pay a deductible, but typically have fixed copays for routine doctor’s office visits. These health plans have yearly limits on your out-of-pocket health care costs, after which you pay nothing for the remainder of the year.
No. A person must meet a few conditions to be eligible for a Medicare Advantage plan. If you wish to enroll in a Medicare Advantage plan, you must:
- Be eligible for Medicare
- Be enrolled in both Medicare Part A and Medicare Part B (you can check this by referring to your red, white, and blue Medicare card)
- Live within the plan’s service area (which is based on the county you live in – not your state of residence)
- Not have end-stage renal disease (ESRD).
No. Once enrolled in a Medicare Advantage Plan, the private company offering your plan will take over some of the administrative processes to implement your Medicare benefits; however, you do not lose your Original Medicare. If you wish to leave a Medicare Advantage plan, you can return to your Original Medicare Part A and Part B coverage during next the Annual Election Period (AEP) which is October 15th through December 7th.
No, Medicare Advantage does not replace Medicare and is not a supplement. A Medicare Advantage plan works differently than a Medicare supplement plan. A doctor or hospital must agree to accept the plan’s “Terms and Conditions” prior to providing health care services to a customer (with the exception of emergencies).
There are only a few primary types of Medicare Advantage Plans and most of the different Medicare Advantage Plans include prescription drug coverage:
- Health Maintenance Organization (HMO) - A Health Maintenance Organization that is contracted with Medicare provides you with access to a network of doctors and hospitals that coordinate your care, with an emphasis on prevention. This allows you to get more benefits than the Original Medicare Plan and many Medicare Supplement plans. With an HMO, your care may not be covered if you go outside the HMO network without obtaining prior approval.
- Health Maintenance Organization with a Point of Service Option (HMO POS) - This HMO provides a more flexible network, allowing you to seek care outside of the “traditional HMO network” under certain situations or for certain treatment. You may pay some additional fees for using the POS (out-of-network) option.
- Preferred Provider Organization (PPO) - A Preferred Provider Organization provides access to a network of doctors and hospitals that coordinate your care. PPOs have a network of doctors and facilities, but also allow you to use any doctor or hospital outside of the network for a higher copay or coinsurance.
- Private Fee-For-Service (PFFS) - A Private Fee-For-Service Plan is a type of Medicare Advantage plan in which you may go to any Medicare-approved doctor or hospital that accepts both Medicare and the plan’s terms and conditions. The health insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you receive. You may pay more or less for Medicare-covered benefits. The PFFS plans are the most flexible, but a doctor or hospital can make patient-by-patient or visit-by-visit decisions of whether to accept the PFFS Plan Member.
- Medicare Special Needs Plans (SNPs) - A Special Needs plan is a Medicare Advantage plan with coverage designed especially for Medicare beneficiaries with certain chronic conditions (such as diabetes), or have some other specific need.
- Medicare Medical Savings Account (MSA) - A Medical Savings Account is a combination of a high-deductible health plan and a bank account where your health insurance plan deposits a certain amount of money per year. You use the money in your account to pay for Medicare Part A and Medicare Part B expenses, and when your plan deductible is met, the Plan pays for any further Medicare-covered services. MSAs do not offer Medicare Part D prescription drug coverage.
No. Each Medicare Advantage plan is different. Although all Medicare Advantage plans must cover at least the Medicare “Medically-Necessary Services,” Medicare Advantage Plans can charge different deductibles, offer co-payments (for instance $30 per office visit) or various co-insurance terms (such as 20 percent of the procedure cost). Some Medicare Advantage plans have a limit on how much you can spend in a year. Medicare Advantage plans may also offer additional services such as eye care, dental care, and fitness programs.
It is of course important to compare the benefits between your current coverage and the Medicare Advantage plan. Be sure that you understand the additional benefits and any benefits (or freedoms) that you may lose. In particular, be sure to look at the following:
- Can you change your current doctors or are they in the new plan’s network?
- If prescription drug coverage is provided, are your medications on the plan’s formulary?
- How much is the monthly premium?
- How much will your coverage cost? Co-payments and co-insurance are explained in the plan’s Summary of Benefits or Evidence of Coverage.
- Which additional services are offered, such as preventive care, vision, dental, and health club membership?
- Are there any treatments that you need that are not covered by the plan?
- Can you work within the network restrictions (such as paying extra when you visit a doctor who is out-of-network)?