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.
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.