Medicare Advantage
What is it?
Medicare Advantage, also known as Medicare Part C, is a way of combing Medicare coverage into a single plan that is administered by a private insurance company. Most MA plans have prescription drug, dental, vision and hearing coverage as well.
Medicare Advantage (Part C)
What are Medicare Advantage Plans and how do they work?
Medicare Advantage plans are individual health insurance plans that are sold and administered by private insurance companies that have been approved by Medicare. Medicare Advantage plans are considered “all-in-one” plans that are required to at least offer all of the benefits from Original Medicare (Parts A & B) and most plans offer extra benefits such as prescription drugs, dental, vision, and hearing coverage.
What is Covered by Medicare Advantage Plans?
- All the benefits of Part A
- All the benefits of Part B
- Most plans offer Part D coverage (Prescription drug coverage)
- Dental exams, x-rays, cleaning
- Eye exams, lenses and eyeglasses
- Hearings tests and hearing aids
- Fitness memberships and health/wellness programs
- Most have extra benefits such as transportation to medical appointments and virtual doctor visits
What are my Costs?
Costs vary by plan and insurance company. Some of the costs that you will need to pay if you enroll in a Medicare Advantage plan include:
- Medicare Part B Premium: If you elect to enroll in a Medicare Advantage plan, you are still responsible for your Part B premium witch is $170.10 per month in 2021.
- Premium: Most Medicare Advantage plans have a zero dollar monthly premium. Some plans do have monthly premium which typically have richer benefits and lower cost sharing compared to a zero dollar premium plan.
- Copayments and Coinsurances: Most Medicare Advantage plans charge a copay for different services. Some of these services include seeing your doctor, specialist visit, and prescription drug refill. These costs vary by plan.
Keep in mind that individual health care needs is a major factor in how much you can expect to pay out of pocket. All Medicare Advantage plans have something called Maximum Out-of-Pocket (MOOP) which limits your annual out of pocket costs for healthcare. Once you hit your MOOP, the plan pays for 100% of all covered services.
Who is Eligible and how do I join a Medicare Advantage Plan?
Anyone that is already enrolled in Medicare Part A and Part B is eligible to join a Medicare Advantage plan. This includes anyone that is age 65 and older, anyone who is receiving Social Security Disability for at least 24 months, and anyone diagnosed with end stage renal disease (ESRD) or ALS. Private insurance companies that offer Medicare Advantage plans are required to accept all eligible beneficiaries regardless of age or health condition.
Once you are enrolled in Original Medicare, you may being searching for a Medicare Advantage plan in your geographic location. You can enroll in a Medicare Advantage plan using a few different methods. You can using Medicare’s Plan Finder tool on the Medicare.gov website, you can contact the insurance company directly, or you can use us, an independent Medicare broker that can help find the best plan for you. We are licensed and contracted with numerous insurance companies and can compare and contrast all of the plans available to you, all for no cost to you.
When can I join a Medicare Advantage Plan?
If you are considering enrolling in a Medicare Advantage plan, there are some very important dates you need to know.
- Initial Enrollment Period (IEP): This is a seven month window that starts three months before your 65th birthday month and three months afterwards. During this time you can enroll in all parts of Medicare with no penalties, this includes Original Medicare (Parts A & B), Medicare Advantage (Part C), Prescription drug coverage (Part D), and Medicare Supplement plans
- Annual Enrollment Period (AEP): October 15 – December 7 every year. During this time you can sign up for a Medicare Advantage plan, or if you have a Medicare Advantage plan you can change plans or revert back to Original Medicare. You can also change Part D plans if you are enrolled in a standalone plan. Coverage begins January 1.
- Open Enrollment Period (OEP): January 1 – March 31 every year. During this time you can only make switch from one Part C plan to another Part C plan or revert back to Original Medicare. You cannot enroll in a Medicare Advantage plan if you currently have Original Medicare.
Types of Medicare Advantage Plans
Medicare Advantage plans are known as Coordinated Care Plans. Coordinated Care Plans use networks of providers and location to provide service to their beneficiaries. As such you need to permanently reside in a service location to be eligible for a MAPD plan. Typically, In-network providers have lower out of pocket costs compared to Out-of-Network providers. Below are the different types of MAPD plans available.
HMOs utilize a network of providers to deliver care to Medicare beneficiaries. Medicare Advantage HMO plans have come a long way in the past few years and most insurance companies have broad networks with numerous providers and specialists that plan enrollees can use. Most HMO plans have lower copays and coinsurances than plans that allow you to use out-of-network providers such as a PPO plan. Typically you must receive care from in-network providers for the care to be covered by your plan except for emergency care, urgent care or dialysis. Out of network services are typically not covered. In most cases, you will be required to select an in-network Primary Care Physician (PCP) before enrolling in the plan. Some but not all HMO plans require a referral from your PCP before seeing a specialist. Prior authorization from the plan for certain services can be required for the service to be covered, otherwise you might have to pay for the full cost of the service out of pocket. Most HMO plans include prescription drug coverage but if you enroll in an HMO plan without prescription drug coverage, you cannot join a separate drug plan. HMOs also include dental, vision, and hearing coverage.
Key Point: HMOs utilize a network of providers that you must use for services in exchange for lower cost sharing (copays, coinsurance, deductibles).
PPOs are similar to HMOs in many aspects, but there are three big differences. First, while PPOs also utilize a network of providers to deliver care, you are not required to use in-network providers, out-of-network providers may be used but typically at a higher cost to you than using an in-network provider. Secondly, you are not required to select a Primary Care Physician (PCP) before enrolling in the plan. Lastly, in most cases, you do not need a referral to see a specialist. Like HMOs, prescription drug coverage is included in most plans but if you enroll in a plan without drug coverage you cannot enroll in a separate plan for drug coverage. PPOs also include dental, vision, and hearing coverage.
Key Point: PPOs utilize a network of providers but you are given the flexibility to use out-of-network providers if you wish, but at a higher cost compared to in-network providers.
PFFS plans allow you to see any Medicare-approved doctor or other health-care provider so long as they accepts the plan’s payment terms, agrees to treat you, and accept Original Medicare. Not all providers will accept the conditions for a PFFS plan and can elect to treat you or not at every visit. It is very important that you make sure the doctor and hospital agrees to the plan’s terms before receiving care or else you could be left paying for the full cost out of pocket (except for in emergency situations). Some PFFS plans have contracted in-network providers which offer lower cost sharing compare to out-of network providers. Much like PPOs, you do not need to chose a Primary Care Physician (PCP) and you do not need a referral to see a specialist. Prescription drug coverage can be included in PFFS plans, but unlike HMOs and PPOs, if you plan does not include drug coverage, you are allowed to sign up for a standalone Part D prescription drug plan. PFFS can plans also include dental, vision, and hearing coverage.
Key Point: PFFS plans allow you to receive care from any provider so long as they accept your plan’s terms and accept Original Medicare.
An MSA plan combines a high-deductible health plan with a special savings account. Medicare deposits money into an account that can be withdrawn tax-free to pay for approved healthcare services. There are no networks so can use any provider that accepts Medicare. There is no prescription drug coverage with an MSA plan so if you want drug coverage you must purchase a standalone Part D plan. Some plans have coverage for dental, vision and hearing, usually for an extra cost.
There are three types of special needs plans available to those that meet the eligibility criteria. All SNPs have prescription drug coverage.
- Chronic Condition SNP (C-SNP): C-SNPs are for people living with severe or chronic conditions. This includes but is not limited to diabetes, cancer, chronic heart failure, dementia, ESRD, HIV/AIDS, and mental health disorders. For a full list of specific conditions please visit Medicare.gov.
- Dual Eligible SNP (D-SNP): D-SNPs are for people that are entitled to both Medicaid and Medicare services.
- Institutional SNP (I-SNP): I-SNPs are for those that are living in a skilled nursing facility or an institutional facility,
Have a Licensed Medicare Specialist call you today!
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