MEDICARE ADVANTAGE PLANS OVERVIEW (PART C)
A Medicare Advantage Plan (such as an HMO,POS,PPO,SNP,PFFS and MSA) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called "Part C" or "MA Plans" are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. 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 aren't supplemental coverage.
Some Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the services included.
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). These rules can change each year.
There may be several private companies that offer different types of Medicare Advantage Plans in your area. Each plan can vary. Read individual plan materials carefully to make sure you understand the plan's rules. You may want to contact the plan to find out if the service you need is covered and how much it costs.
If you have other coverage it's very important to talk to your employer, union, or benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose employer or union coverage. In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the plan you join. Remember, if you drop your employer or union coverage, you may not be able to get it back.
If you join a Medicare Advantage plan, review the Evidence of Coverage (EOC) and Annual Notice of Change (ANOC) your plan sends you each 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 that will be effective in January. If you don't get an EOC or ANOC, contact your plan.
Types of Medicare Advantage Plans
Congress added Medicare Advantage plans to give Medicare participants more choices about how they receive their health care. That's why you'll find different kinds of plans in this category. Medicare Advantage plans are all offered by private companies that have been approved by Medicare. To encourage competition, Medicare gives the private companies flexibility in setting the terms of each plan. That means you'll find considerable variation among plans as you shop.
In four kinds of Medicare Advantage plans, HMO, POS, PPO, and SNP, your care is "coordinated". That means the plan may coordinate your coverage through a primary care physician who manages the care you receive from specialists and hospitals. You may have to choose specific doctors and hospitals. This is different from Medicare Part A and Part B, where you can visit any doctor or hospital that accepts payment from Medicare. The other two types of Medicare Advantage plans, Private Fee-For-Service (PFFS) plans and Medical Savings Account (MSA) plans do not use coordinated care. In these plans, you can get care from any provider who is willing to accept the terms, conditions, and payment rates each time they furnish covered services for you.
How do HMO, POS & PPO plans differ from Medicare Parts A and B?
These plans usually take a broader view of your care than Parts A and B do. These plans cover all of the care covered by A and B (except for hospice care, for which you can still receive coverage under Medicare Part A), but they also often include additional care designed to help you stay healthy. Some plans offer nurse help lines and other resources that can help you take a more active role in your health care. Plan networks also work to improve the quality of care through management techniques for the providers in the network. Unlike Part A and Part B, these plans may have some limits on your choice of doctors and hospitals. The limits depend on the type of plan.
In an HMO-type plan, you must use doctors who belong to the plan, or go to hospitals in the network, for your care. If you go outside the network for care, other than emergency care, urgent care, or out of area real dialysis, you must pay for your own care. These plans may require you to choose a primary care physician. This doctor may then manage any care you receive from specialists. In some plans, you may need a referral from this physician to see a specialist.
A POS plan is a type of HMO plan that allows members the ability to visit doctors and hospitals outside their network for some covered services, usually for a higher copayment or coinsurance. Some POS plans do not require referrals for specialty services.
In a PPO-type plan, you are likely to have more freedom to choose your doctor. These plans typically don't require you to have a referral to see a specialist. And you can see doctors outside the network without having to pay the entire cost yourself. If you do visit a doctor or hospital outside the network, though, you'll usually pay a larger share of the cost of your care. PPO plans offer access to in-network and out-of-network healthcare providers. You'll usually pay more if you use providers outside the network; sometimes you'll pay the entire cost.
Special Needs Plans (SNP):
Medicare Advantage Special Needs Plans are care management plans, a special type of coordinated care plan designed for people with special needs. They combine hospital care and doctor's visits and other outpatient care in a single plan. Because people who qualify for Special Needs Plans often need a considerable amount of medical care, these plans usually focus on helping members receive well-coordinated care. Some offer care managers or nurse practitioners who act as advocates to help members get the care they need when they need it.
How do Special Needs Plans differ from Medicare Parts A and B?
Special Needs Plans(SNP)may serve people in any of these groups: People who are institutionalized in a nursing home or other long-term-care facility because they are unable to care for themselves People who are eligible for both Medicare and the Medicaid assistance program People with certain chronic diseases, such as diabetes or heart disease Some Special Needs Plans currently available serve people who are institutionalized or people who are eligible for both Medicare and Medicaid (sometimes called dual eligible' s). Some plans serve people who are both institutionalized and eligible for Medicaid. A few plans focus on helping members deal with chronic conditions like diabetes. These plans are run by private companies. They use a network of doctors and hospitals working together to provide care. Each plan creates its own network.
How to choose a Special Needs Plan (SNP):
If you are interested in a Special Needs Plan, contact the plan to learn more about who's eligible. Some plans may have eligibility requirements beyond just being eligible for Medicare. For example, you might need to qualify for Medicaid to join some plans. You can join a Special Needs Plan at any time during the year as long as you're eligible. Like other Medicare Advantage plans, details of items like premiums and cost sharing vary from plan to plan. Pay careful attention to the details of the plan before you choose.
Private Fee-For-Service Plans (PFFS):
Medicare Advantage Private Fee-For-Service (PFFS)Plans are a recent addition. These plans are different than an HMO, POS, PPO, SNP or Medigap supplement plans.
How are (PFFS) plans different from Medicare Part A and Part B?
One major difference between Private Fee-For-Service Plans (PFFS) and Medicare Parts A and B is that enrollees join a plan run by a private company. Enrollees of these plans typically visit any Medicare eligible provider who is willing to accept the plan's payment terms and conditions. It is important to confirm that the provider accepts payment from a specific plan each time services are provided. Doctors or hospitals are not required to agree to accept the plan's terms and conditions, and thus may choose not to treat you. Some providers do not accept Private Fee-For-Service plans, or accept only certain Private Fee-For-Service plans. You can receive services throughout the United States. Some of these plans do not offer prescription drug coverage. If you choose one of these plans and want drug coverage, you'll need to buy a stand-alone Medicare Part D prescription drug plan. Many of these plans do offer a broader choice of covered services than Parts A and B. Some cover additional services, like nurse help lines.
Medical Savings Account Plans:
A Medical Savings Account (MSA) plan is a type of Medicare Advantage plan that combines coverage for Medicare Part A and Part B services with a special savings account fund you can use to pay for covered expenses tax-free. The plan combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible) and you can use the money to pay for your health care services during the year.
Once you have paid a deductible, the plan covers your Medicare-covered expenses. Like other Medicare Advantage plans, terms vary from plan to plan.
Your Share of Medicare Advantage Plan (Part C) Costs
These costs vary from plan to plan. Shop around for a plan that best fits your needs. In Medicare Advantage plans, the company that offers the plan sets the premium and decides on the cost sharing. You'll need to look carefully at the details of each plan you're considering. If you join a Medicare Advantage plan, you will continue to pay your Part B premium. The plan may also charge its own premium, although some Medicare Advantage plans do not. The premiums you may pay for Medicare Advantage plans can vary widely. Insurers can change the premiums and other terms of the plan from year to year. In the fall, insurers announce next year's premiums and other terms of their plans.
Most Medicare Advantage plans use a combination of deductibles, coinsurance, and copays to share the costs with you. These cost sharing arrangements will usually apply to all of the services the plan covers, hospital stays, doctors visits, drug coverage if you have it, and so on.
You will need to investigate the details of a plan to get the full story on its cost sharing. Plans vary widely, and their cost sharing usually works quite differently from the cost sharing used in Original Medicare (Parts A and B). For example, in Part A, your cost sharing for a five-day hospital stay would be your $1,600.00 hospital deductible (2023). In a Medicare Advantage plan, you could pay between $225 to 395 per day copay for each day in the hospital. This is just an example, and each plan may vary.
Limits on your cost sharing are another way Medicare Advantage plans may differ from Original Medicare(Parts A and B). In Original Medicare (Parts A and Part B), there are no limits on your out-of-pocket spending for cost sharing. And in some situations, like extremely long hospital stays, your coverage under Part A ends entirely, and you become responsible for paying all of your own costs. In contrast, beginning in 2011, all Medicare Advantage plans offer a feature that caps your out of-pocket spending for cost sharing like copay's and deductibles in any given year. The out-of-pocket maximum will vary by plan.
Drug cost sharing:
Cost sharing for drug coverage that is built into Medicare Advantage plans generally works in ways that are similar to cost sharing in stand-alone Medicare Part D plans. Please click on our tab Prescription Drug Plans to see more information on how these plans work. It is extremely important to understand that the costs you will incur in the prescription drug plan you select are in large part determined by the costs of the specific drugs you are using, therefore it's imperative that you compare each Medicare Advantage plan you are considering joining to see how your specific drug utilization will affect your costs.
Choosing a plan:
Many people who choose a Medicare Advantage plan choose an HMO, POS,PPO, or SNP. If you're interested in a Medicare Advantage plan, you'll need to do some homework. Look at the premium (if any) you'll pay to join. Then estimate your total cost sharing for services. Find a Medicare Advantage plan where the cap, or maximum on your out-of-pocket spending, fits your budget. Consider whether a plan's network gives you access to the doctors you want to see.
If you want prescription drug coverage, be sure to join a plan with prescription drug coverage built in. However, if you have employer or union prescription drug coverage it may pay to join a Medicare Advantage plan that does not include prescription drug coverage and retain your employer or union drug plan coverage.
Always check to see how much your specific prescription drugs will cost under each plan you are considering. These costs can vary significantly and can have a huge impact on your overall costs. Also always check with your employer and or union to confirm that you can retain your drug plan with them after joining a Medicare Advantage plan.
Common Medicare Advantage Questions:
Original Medicare (Parts A & B) has coverage limits, cost-sharing requirements and provider networks that will influence the who, what, when and where of how patients can receive medical care. It will also stipulate how much you will pay for that care.
Sometimes, you might feel that Original Medicare doesn’t offer you truly the best coverage and cost benefits for the care you need to receive. That’s where Medicare Advantage plans can step in. These plans take all of the benefits of Original Medicare and make them more adjustable, while also offering coverage for certain care that Original Medicare doesn’t include. With Medicare Advantage, you will get more flexibility for the care you need, at costs you can afford.
Medicare Advantage plans are approved and regulated by the Medicare system. However, they are offered by various private insurers and come in various forms, including:
HMOs (Health Maintenance Organizations)
HMO-POS (HMO Point-of-Service)
PPOs (Preferred Provider Organizations)
PFFS (Private Fee-for-Service Plans)
SNPs (Special Needs Plans)
All Advantage plans vary. They will include different provider networks, cost-sharing rules and premiums. Therefore, some will be better for you than others. Work with your agent to choose the plan that will offer you the most appropriate coverage for your medical goals.
Medicare Advantage plans must offer you nearly all of the same benefits as Original Medicare, and benefits will be subject to standards set by Medicare regulations.
Where they differ from Original Medicare is that they also offer expanded benefits like:
With these extra benefits, you can receive covered care for conditions that might not need attention now but could arise later.
Your Medicare Advantage plan’s price will vary based on the insurer and plan you choose. You will remain a participant in the Original Medicare program despite also having Medicare Advantage coverage. You must continue to pay your Medicare Part B premium in addition to the premium added by your Medicare Advantage plan.
You must have both Original Medicare Part A & Part B coverage before you can enroll in a Medicare Advantage plan.
There are also only certain times that you can enroll in or make changes to a plan:
Medicare Initial Enrollment: You can enroll in Advantage plans during initial enrollment. This is a seven-month period around your 65th birthday.
Special Enrollment Periods: Depending on special circumstances, you might qualify for a special enrollment period for your Advantage plan.
Certain Medicare Advantage plans are not available in all areas, and if you qualify for Medicare because you have ESRD (End-stage Renal Disease), then you might not qualify for Medicare Advantage.