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Medicare Part C (Medicare Advantage)

A Medicare Advantage Plan is a program where private companies approved by Medicare offer health plans that cover all Medicare Part A and Part B benefits. The Medicare Advantage Plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage instead of Original Medicare. Many Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs, many include Medicare prescription drug coverage (Part D) referred to as MA-PD plans and Medicare Advantage Plans offer a maximum out-of-pocket limit.

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care) and these rules can change each year.

How Much Does a Medicare Advantage Plan Cost?

With some plans you do not have to pay an additional premium you are only required to pay your Part B premium. However each Medicare Advantage Plan can have different out of-pocket costs and copays that vary depending on the specific plan depend on.

Click here for other considerations when choosing your plan:

  • Whether the plan charges a monthly premium.
  • Whether the plan pays any of your monthly Part B premium.
  • If you qualify for Medicaid it may help you with costs.
  • Whether the plan has a yearly deductible or any additional deductibles.
  • How much you pay for each visit or service (copayments or coinsurance).
  • The type of health care services you need and how often you get them.
  • Whether you will be using network providers or not will help you choose the type of plan.
  • Whether you need extra benefits and if the plan charges for them.
  • The plan’s yearly limit on your out-of-pocket costs for all medical services.
  • Do you want a plan with Prescription Drug Coverage known as an MA-PD plan

What Does a Medicare Advantage Plan Cover?

In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans are not supplemental coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs and many include prescription drug coverage (Part D).

Different Types of Medicare Advantage Plans
Click on a Plan below to view its description:

    HMO and HMO (POS) Point of Service Information (click to expand and view/close)

    HMO Plans

    • Generally, HMO enrollees must use plan network doctors and hospitals within the plan’s service area to receive most covered services.
    • Emergency and urgently needed services received outside of the plan network are covered
    • When the enrollee is temporarily absent from the plan’s service area, dialysis services are covered.
    • In most other cases, if enrollees get care out-of-network without prior approval from the plan, they will have to pay for it themselves.
    • HMOs must have a maximum limit on member out-of-pocket costs of not greater than $6,700 per year and many plans have lower limits

    (HMO POS) Plans— is an HMO plan that may allow you to get some services out-of-network for a higher cost.

    • Option that allows enrollees to go to non-plan doctors and hospitals generally without receiving prior approval for certain services.
    • Cost sharing is generally higher than for services obtained from network providers.
    • Enrollees may need to select a primary care doctor and may need a referral for specialty care.
    • If an enrollee needs a type of specialist who is not in the plan’s network, the plan will arrange for care outside of the network.

    Provider Organization (PPO) Plans (click to expand and view/close)

    • PPO enrollees generally may get care from any provider in the U.S. who accepts Medicare, but will pay less if they go to one of the “preferred” providers in the PPO’s network.
    • Enrollees usually will pay higher cost-sharing if they get care from a non-preferred provider.
    • PPOs must have a maximum limit on member out-of-pocket costs for network providers of not greater than $6,700 per year and an aggregate limit on network and non-network costs of $10,000.
    • Enrollees do not need a referral to see a specialist or out-of-network provider, but may be encouraged to contact the plan to be sure the service is medically necessary and will be covered.

    Private Fee-for-Service (PFFS) Plans (click to expand and view/close)

    • PFFS enrollees may receive covered services from any provider in the U.S. who participates in Medicare and agrees to accept the plan’s terms and conditions of payment
    • Some PFFS plans contract with network providers and if the PFFS plan has a network, enrollees usually pay more if they see out-of-network providers.
    • Except for emergencies, enrollees must inform providers before receiving services that they are PFFS plan members so the non-network providers can decide whether to accept the plan’s terms and conditions.
    • Non-network providers may, on a patient-by-patient, and visit-by-visit basis decide whether to treat the beneficiary.
    • Non-network providers that accept Original Medicare may choose not to accept PFFS plan enrollees.
    • PFFS is not the same as the Original Medicare plan that is offered by the Federal Government.
    • PFFS is not a Medicare supplement, Medigap, Medicare Select policy, or stand-alone Prescription Drug Plan.

    Special Needs Plans (SNP) - Contact for finding your state's medicaid program (click to expand and view/close)

    • Dual Eligible SNPs – serve beneficiaries eligible for both Medicare and Medicaid (dual eligibles);
    • Chronic Care SNPs – serve beneficiaries with certain severe or disabling chronic conditions, such as diabetes;
    • Institutional SNPs – serve beneficiaries in long-term care facilities within the plan’s network as well as beneficiaries living in the community, but requiring an institutional level of care.ĽAll SNPs provide Part D prescription drug coverage.
    • Here is a link to find your state contact for Medicaid to see if you qualify (click here)

    Medical Savings Account (MSA) Plans (click to expand and view/close)

    • Medical Savings Account (MSA) Plans— Is a plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year.
    • A Medicare Medical Savings Account is a high deductible health plan combined with a savings account for health care expenses. Medicare makes a contribution to the beneficiary's savings account.
    • MSA enrollees pay for health care expenses from the savings account and then out-of-pocket until the annual deductible is met, after which the plan pays 100% for covered services.
    • The maximum deductible for MSA plans in 2015 is $11,200.
    • MSAs cover Part A and Part B benefits, but not Part D Medicare prescription drug benefits.
    • Beneficiaries may enroll in a stand-alone PDP.
    • Enrollees pay the Part B premium but no plan premium except for any premium for supplemental benefits

    Medicare 1876 Cost Plans (click to expand and view/close)

    • Cost plan enrollees can choose to receive Medicare-covered services:
      • Under the plan’s benefits by going to plan network providers-Plan cost sharing applies
      • Under Original Medicare by going to non-network providers-Original Medicare cost sharing applies
    • Cost plans may offer Part D prescription drug coverage as an optional benefit.
    • Cost plans may offer other optional supplemental benefits.

Additional things to know about Medicare Advantage Plans

When you can sign-up or change plans? Only during certain enrollment periods.

  1. If you are turning 65 or becoming elegible for for the 1st time the Initial Enrollment Period (IEP) you can enroll in a Medicare Advantage Plan during the same 7 months you are eligible to enroll in Medicare which are 3 months prior to your month of eligibility, during the eligible month and 3 months following the month of eligibility. Your plan would be effective on the 1st day of month you turn 65 or the month following the election.
  2. You can only make changes to your plan during the Annual Enrollment Period (AEP) from October 15 to December 7 for coverage to begin January 1 of the following year*, unless you qualify for a Special Election Period (SEP).
  3. You can you can also leave your Medicare Advantage Plan and switch to Original Medicare between January 1–February 14 during the Medicare Advantage Disenrollment Period (MADP). If you switch to Original Medicare during this period, you will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form.
  4. Special Election Period (SEP) has requires you have special circumstances and you may quailfy to change if you meet the critieria.
  5. 5-Star SEP is one time per year when you can move from a non 5 star plan to a 5 star plan (see Medicare and You handbook)

Unless you are in one of these periods, you cannot:

  • Switch from Original Medicare to a Medicare Advantage Plan.
  • Switch from one Medicare Advantage Plan to another.
  • Switch from one Medicare Prescription Drug Plan to another.
  • Join, switch, or drop a Medicare Medical Savings Account Plan.

FACTS about a Medicare Advantage Plan (click to view)

  • As with Original Medicare, you still have Medicare rights and protections, including the right to appeal.
  • Check with the plan before you get a service to find out whether they will cover the service and what your costs may be.
  • You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan.
  • You can join a Medicare Advantage Plan even if you have a pre existing condition, except for End-Stage Renal Disease.
  • You can only join a plan at certain times during the year. In most cases, you’re enrolled in a plan for a year.
  • If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan.
  • If the plan decides to stop participating in Medicare, you‘ll have to join another Medicare health plan or return to Original Medicare.

What do I do Now or How Do I Get a Medicare Advantage Plan?

Not all Medicare Advantage Plans work the same way, so before you join, take the time to find and compare Medicare Health Plans in your area.  Once you understand the plan’s rules and costs, you may be able to join by completing a paper application, calling the plan, or enrolling on the plans website. Medicare also has information on quality to help you compare plans and we can help you with this click here to go to our contact page or use our click to call button to call us now for free

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