MEDICARE ADVANTAGE PLANS




Medicare Advantage expands health care options for Medicare beneficiaries.  Enrollees are eligible for Medicare Advantage/Medicare Part C if they are:

...entitled to Medicare Part A and enrolled in Medicare Part B
... permanently reside in the plan service area.

The Initial Coverage Election Period (ICEP) occurs 3 months before an individual is entitled to both Medicare Part A and B to 3 months afterwards.

Note that enrollees generally cannot change plans during the year except during:

Annual Coordinated Election Period
... Changes can be made to both health and prescription drug coverage
... MA plans must accept new members during this period unless they have a capacity waiver
... Occurs from November 15th to December 31
... Coverage begins on January 1

MA Open Enrollment Period
... Individuals can make changes to health coverage ONLY - no changes to prescription drug coverage
... Individuals can join a new MA plan, switch MA plans or choose to be in the Origianl Medicare plan
... Occurs from January 1 to March 31
... Changes are effective the month after the plan receives the request to enroll

Special Enrollment Period
SEPs have no specific time as they depend on member's circulstances but they must have Medicare Parts A and B.
Acceptable circumstances include
...... moving out of service area
...... new health and/or drug options become available
...... plan leaves Medicare program
...... plan reduces its service area
...... enrollee loses creditable prescription drug coverage
...... enrollee qualifies for "extra help" from Medicare
...... enrollee moves into, resides in or movesout of a long-term care facility such as a nursing home
...... if individual filed a grievance against the plan

Note that an individual can switch from MA to Original Medicare anytime within the first 12 months of their MA Plan Coverage, including
... those who joined an MA plan when they turned 65 or if they were eligible for Medicare due to a disability
... Individuals who were in Original Medicare and dropped a Medigap Policy when they joined an MA plan for the first time.

With Medicare Advantage (also called Medicare Part C), you can choose from new ways in which to receive your Medicare benefits. 

It is important to remember that each of these options will have advantages and limitations, and no option will be right for everyone.  Also, not all options will be available in all areas. 

HMO (Health Maintenance Organization) A Medicare Advantage Plan that must cover all Part A and Part B health care.  In most HMOs you can only go to doctors, specialists, or hospitals in the plan´s network except in an emergency.  You can have $0 premium and low copays.

 

PPO (Preferred Provider Organization)  A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals and providers that belong to the network.  You can use doctors, hospitals and providers outside of the network for an additional cost.         

 

PFFS (Private Fee-for-Service Plan)  A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan´s payment and terms and conditions.

 

SNP (Special Needs Plan)  A special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home or have certain chronic medical conditions.

 

MSA (Medical Savings Account)  MSA Plans combine a high deductible Medicare Advantage Plan and a bank account.  The plan deposits money from Medicare in the account.  You can use it to pay your medical expenses until your deductible is met.

 

MEDICARE COST PLAN  If you get services outside of the plan´s network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan.  Your Cost Plan pays for emergency services, or urgently needed services.




Medicare Advantage Plans are health plan options that are subsidized by the government to provide additional health coverage to Medicare Part A and Part B. Medicare Advantage Plans include HMOs, PPOs, PFFS and Medicare Special Needs Plans. Generally, Medicare Advantage Plans have little or no monthly premiums. Instead, seniors pay co-payments for doctor visits, hospitalization and other medical services.

Medicare beneficiaries are given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as "Medicare+Choice" or "Part C" plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, "Medicare+Choice" plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as "Medicare Advantage" (MA) plans.

Traditional or 'fee-for-service' Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country.  Private fee-for-service plans (PFFS) are required to have providers agree to their terms and fees.

For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a set amount every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited on the providers they can receive services from without paying extra. Typically, the plans have a 'network' of providers that you can use. Going outside that network may require permission or extra fees.

Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower co-payments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members´ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan's network or 'panel' of providers.



 For further definitions, and our recommendation with reasons why, see MEDICARE SUPPLEMENTS FOR AGE 65+ page on this site, and scroll down to MEDICARE ADVANTAGE PLANS.  You may find our recommendation a perfect "fit" for your needs and wants.

 

Medicare Advantage Plans

  • Help pay for hospital costs, doctor´s visits, and other medical services
  • May also include built-in Medicare prescription drug coverage (Part D) often at no additional premium
  • Typically provide additional benefits, like preventive care, that Original Medicare doesn´t cover
  • Have plan premiums not based on age or health
  • Combine all benefits and services in one plan
  • Come in several different forms:
    • Health Maintenance Organizations (HMOs)
    • Preferred Provider Organizations (PPOs)
    • Point of Service (POS)

HMO Plans

  • Single card convenience
  • Include plans starting at $0 monthly premiums
  • Provide additional benefits and services not covered by Original Medicare
  • May include Medicare prescription drug coverage (Part D)
  • Access to a local network of doctors
  • Do not require a referral to see a specialist, in many plans

PPO Plans

Offer all of the benefits of HMO Plans plus:

  • Freedom to receive care from provider of choice
  • Allows your client to maximize their benefit when they receive care inside the plan´s network of providers. Going outside the network for covered services generally costs more money.

POS Plans

Point of Service Plans allow your client to:

  • Visit doctors outside their network (but with less coverage than within their network)
  • Have access to more preventive care and wellbeing services, such as discounts to health clubs and quit smoking programs

Special Needs Plans

Special Needs Plans are for people with special needs. There are three basic types of plans for:

  • People with chronic conditions like cardiovascular disease, asthma, heart failure, hypertension, arthritis, chronic obstructive pulmonary disease (COPD), diabetes or dementia
  • People living in nursing homes, long-term care or assisted living facilities
  • People eligible for both Medicare and Medicaid (state medical assistance)


Here´s what Special Needs Plans can do for your client:

  • Help pay for hospital costs, doctor´s visits, and other medical services (Medicare Parts A & B)
  • Include built?in prescription drug coverage (Part D) often at no additional premium
  • Provide additional benefits, like preventive care, that Original Medicare doesn´t cover
  • Combine all benefits and services in one plan


PFFS Plan

A Private-Fee-for-Service Plan offers the ability to control out-of-pocket expenses while providing the flexibility of provider selection. Here are some advantages of a PFFS Plan:

  • Choice of any doctors and hospitals who agree to accept the plan´s terms and conditions each time your client seeks services
  • Visit any specialist without getting permission
  • Provides benefits that Original Medicare doesn´t cover
  • Limits out-of-pocket expenses for covered services


IF YOU WANT A MEDICARE ADVANTAGE PLAN
WE RECOMMEND
the AARP MedicareCompleteChoicePlan 2

...No monthly premium
...$3,350 in-network out-of-pocket limit
...$7500 out-of-network out-of-pocket limit
...All Medicare services covered under out-of-pocket limit
...No referral needed for network doctors, specialists, hospitals
...Prescription Drug Plan to $2,700 with Catastrophic Coverage after you pay $4,350 out-of-pocket, no RX Coverage Gap for $1650
...Vision, Dental and Podiatry Benefits
...You may have to pay a separate copy for certain doctor office visits
...For out-of-network, plan covers for travel in the US
PLEASE CALL MARILYN JACOBS (561-988-0070) FOR FURTHER DETAILS

Medicare Part D Plans

PART D:

Our insurer is the 3rd largest insurer

of Part D beneficiaries

With 1,690,000 members

Call Marilyn at 561-988-0070
for more information

Medicare Part D plans help cover the cost of your  prescription drugs. Here are some of the main features of a Part D plan:
  • Provide help with the cost of prescription medications
  • Are only offered through private insurance companies
  • Are usually offered two ways:
    • As a stand alone plan to add coverage to Medicare Parts A and B and as a compliment to a Medicare Supplement plan
    • Or as part of a Medicare Advantage (Part C) plan

  • Have a specific list of approved drugs the cover (called a formulary or drug list)

TOP 5 REASONS to ENROLL in a MEDICARE PART D PLAN
... You've lost your employer coverage
... You are not satisfied with your current plan
... Your drug needs have changed
... You've recently moved
... You want savings, stability and peace of mind

Annual Election Period is from November 15 through December 31.  This is the period when you can change, add or remove health and/or drug plans; enrollment begins January 1st. 

During the Open Enrollment Period from January 1 to March 31, individuals cannot pick up or drop Medicare Prescription Drug plans but they can join a new MA plan, switch MA plans or choose to be in the Original Medicare plan; changes are effective the month after the plan receives the request to enroll. 

Special Enrollment Periods can be at any time for reasons such as enrollee moving out of plans service area; new health plans and options become available; plan leaves Medicare program or reduces its service area; enrollee loses creditable prescription drug coverage; enrollee qualifies for "extra help" from Medicare; enrollee moves into, resides in or moves out of a long-term care faclity such as a nursing home.

NEW ENROLLEES TURNING 65 can generally sign up between 3 months before their 65th birthday up to 3 months after.  Check if you qualify for this Initial Election Period, a one time choice.

If you have any questions about Medicare Advantage Plans, you can email Marilyn at marilynfjacobs@gmail.com or call her at 561-988-0070 to get a Sales Appointment Confirmation Form and make an appointment.