MEDICARE ADVANTAGE PLANS EXPLAINED
Medicare AdvantageMedicare Advantage plans were created under the Balanced Budget Act of 1997 and signed into law by President Bill Clinton. These plans are commonly called Part C of Medicare. Many doctor’s offices call them replacement plans.
Advantage plans for Medicare fall under Part C. These plans often have networks and some plans may require you to get referrals to see a specialist, they are like a traditional insurance plan where you receive all medical and prescription coverage from one card/plan.
These plans were designed by congress to give Medicare beneficiaries a lower-premium option than Medigap. They also have very little Medicare underwriting. This makes them a coverage option for people who missed their open enrollment window for Medigap and now cannot qualify for Medigap due to health conditions.
Medicare Advantage plans are very different than Medigap plans . Members will get their benefits from a private insurance company instead of original Medicare. As we mentioned, sometimes you’ll hear them referred to as Medicare replacement insurance.
Medicare is not really a fan of this language because it’s confusing and not entirely accurate. You never permanently replace your'e Medicare when you join a Medicare advantage plan. Instead you are just choosing to get your benefits from a private company for the rest of the calendar year. You can always return to Original Medicare during any valid election period.
How Medicare Advantage Works, A Medicare Advantage plan is a private Medicare insurance plan that you may join as an alternative way to get your Medicare benefits. When you do, Medicare pays the plan a fee every month to administer your Part A and B benefits and many times part D as well.
You must continue to stay enrolled in both Medicare Part A and B while enrolled in your Medicare Advantage plan. Medicare pays the Medicare Advantage company on your behalf to take on your medical risk.
When on a Medicare advantage plan you will present your Advantage plan ID card at the time of treatment. Your providers will bill the plan instead of Original Medicare. Again, this is also why some providers consider them Medicare replacement plans, but it’s important to remember that you can always return to Original Medicare during a future annual election period.
Each Advantage plan has its own summary of benefits and they will differ greatly at times. This summary will tell you what your copays and other out of pocket expenses will be for various healthcare services. Your plan is required to offer at minimum all the same services as Original Medicare, such as doctor visits, surgeries, lab work and so on.
You might pay $0-$10 to see a primary care doctor. Specialists will often be more – $40- $50 specialist copay is quite common. Some of the higher copays may come in for diagnostic imaging, hospital stay, and surgeries.
You can usually expect to spend several hundred on copays for these items. However, this varies greatly between states, so make sure you review plans in your area to get the specifics on all out of pocket expenses.
One nice thing about Medicare Advantage plans is that some of them offer minor benefits for routine dental, vision or hearing. Some plans include gym memberships. When searching for Medicare Advantage plans with dental and vision.
Most Medicare advantage plans have Networks many times you will fins smaller network plans have lower premiums and out of pocket expenses. Most Medicare Advantage plans have HMO or PPO networks.
Medicare HMO networks generally require to treat only with network providers, except in emergencies. You will usually need to select a primary care physician. That physician can coordinate a referral if you need to see a specialist. There are some HMO plans that offer a point-of-service feature where you can see out-of-network providers in certain circumstances.
Medicare HMO plans are the most prevalent type of network. Currently Medicare advantage HMO make up more than half the advantage plans on the market.
Medicare PPO networks allow you to see doctors outside the network but you’ll have substantially higher out-of-pocket spending to do so.
In limited counties, there are Medicare Private-Fee-for-Service plans. These plans may or may not include Part D. How you access care is also different. While this plan type was very common in the past, it has been slowly phased out in most areas.
Basic Medicare Advantage Rules
If you are deciding between Medicare Advantage and Medigap, you'll want to consider some of the rules before you enroll.
You must tell your providers to bill your Medicare Advantage plan. People who enroll in Advantage plans for Medicare in most cases are choosing that coverage for the rest of the calendar year, to be covered by the plan instead of Original Medicare.
Medicare Advantage Enrollment Periods, Medicare Advantage plans also have lock-in periods. You can enroll in one during the Initial Enrollment Period when you first turn 65. After that, you may enroll or dis-enroll only during certain times of year. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year unless you qualify for a special election period.
The Annual Election Period in the fall is the most common time to change your Medicare Advantage plan. This period runs from October 15th - December 7th each fall. Changes made to your enrollment will take effect January 1.
If you decide to leave a Medicare Advantage plan and return back to Original Medicare, you must notify your Medicare Advantage plan carrier. Otherwise Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare unless you enroll in a stand alone part .
Medicare Advantage Open Enrollment PeriodSome people join Medicare Advantage plans without doing any research about how these plans work or speaking with an agent who can advise them. Therefore they don't know about all of these rules. They may find themselves enrolled into a plan that their doctor doesn't accept or that doesn't include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan.
For this reason, Congress designed the Medicare Advantage Open Enrollment Period that runs from January 1st - March 31st each year. During this time, you can disenroll from any Medicare Advantage plan and return to Original Medicare. You will be allowed to add a standalone Part D drug plan.
Unfortunately, this does not guarantee that you can return to the Medigap plan you had before. Unless this was your first time ever in a Medicare Advantage plan, then you will usually have to answer health questions and go through medical underwriting to get re-approved for Medigap. This is something to Consider this before dropping any Medigap plan to go to Medicare Advantage.
Your other option during the Medicare Advantage Open Enrollment Period is to change from your current Medicare Advantage plan to a different Medicare Advantage plan. Please be aware that you can only use this period once per calendar year.
Medicare vs Medicare Advantage
The purpose of Congress in creating these plans was to give you options in accessing your Medicare benefits. Some reasons why people might choose an Advantage plan are:
Medigap vs Medicare Advantage
Original Medicare with a Medigap plan gives you very comprehensive coverage. The primary differences are that with Medigap plans, you can see any doctor that accepts Medicare. You don't have to ask your doctors if they take your specific Medigap insurance company. The network is Medicare, which has over 1 million contracted providers across the nation.
Some Medigap plans also have fuller coverage on the back end. Medicare pays 80% and your Medigap plan can pay some or all of the other 20%, depending on which Medigap plan you choose. This leaves you with little out of pocket. For example, a beneficiary with a Medigap Plan G won't have the repetitive copays at the doctor that they might incur on a Medicare Advantage plan .
However, Medigap plans do not include Part D coverage, so you will need to purchase a separate stand alone Part D policy. They also do not offer any routine dental, vision or hearing while some Medicare Advantage plans may at least have a little bit of this.
Again, there is no right or wrong. The two types of coverage just work differently. Go with the option that works best for you.
There are the different types of Medicare Advantage Plans:
Medicare HMO plans are a popular managed-care option . According to the Kaiser Family Foundation, approximately 39% of Medicare beneficiaries are enrolled in some type of Medicare Advantage plan and this number has more than doubled since 1999.
Medicare Advantage HMO plans are the most common network-type of Medicare Advantage plans.
Medicare HMOs are popular because of the lower premiums they often offer. In some plans, that premium may be as low as $0. However you must still be enrolled in and paying for Medicare Part B. You usually must also receive treatment with in-network providers except in the case of an emergency.
What is a Medicare HMO?Medicare HMOs are health maintenance organizations through which Medicare beneficiaries can access their Medicare services. They are often called Medicare managed care plans because your care is managed through a network of doctors and hospitals specific to the plan.
The insurance company contracts with certain doctors and physicians in your local area to form a network. You will select a primary care physician (PCP) who will coordinate your care.
If your PCP is unable to treat a health condition, he or she will issue a referral for you to see a specialist network. Some services like preventive care, mammograms and emergency visits may not require a referral. There are some plans may not require referrals for specialty care make sure you confirm this before choosing a plan.
As mentioned above, Medicare HMO plans do not replace Part B. You must first be enrolled in both Medicare Parts A and B before you can enroll in a Medicare HMO. You must also live in the plan’s service area.
When you enroll in a Medicare HMO, you agree to obtain your care through the plan’s network, except in emergencies. Some plans have an HMO-Point of Service (POS) feature. An HMO-POS is a hybrid between HMO and PPO plans. In a POS plan, you can see providers outside the network for certain healthcare services and in certain situations, such as traveling. Always confirm with your plan how their POS feature works in that plan because it can vary.
If a Medicare HMO feels too restrictive to you, consider a Medicare PPO plan which has more flexibility.
Medicare HMO plans have Common Features
Medicare HMOs are generally the most restrictive type of Medicare Advantage plan. There are no out-of-network benefits except in an emergency. All Medicare Advantage plans have certain limitations and restrictions by which you must abide. You can read more about these rules on our general Medicare Advantage page.
How Do Medicare Advantage Companies Make Money?Medicare Advantage plans are paid by Medicare to take on your medical risk. This is why you must remain enrolled in both Medicare Parts A and B while enrolled in a Medicare Advantage plan. The money that you pay for Part B goes towards paying that Advantage company to insure you. Since the Medicare Advantage HMO carrier is getting paid by Medicare for your enrollment, they will offer you premiums as low as possible to attract you to the plan.
Medicare itself is not responsible to pay for any of your services once you enroll in a Medicare Advantage plan. Your'e providers must bill the Medicare Advantage company.
Which Insurance Companies Offer Medicare HMO plans?Medicare HMO plan availability varies by state and county. There are Dozens of well-known insurance companies offer plans, such as Aetna, Anthem, Blue Cross Blue Shield,Humana and Cigna to name a few. Our office can check plan availability in your zip code.
Which Medicare Advantage Plan is Best?Many of our clients often ask us to tell them which Medicare Advantage plan is best.It's just not that simple! Choosing the right Medicare Advantage plan is very much an individual thing there is no one best plan for everyone. A plan might be perfect for you but not great for your neighbor or spouse because his/her doctor isn’t in the network . One plan might have great prices for insulin & diabetes medications, but doesn’t work out so well for someone who takes a different set of medications. Checking your doctors and prescriptions is the first step in determining which plans will work for you.
Medicare does give Medicare Advantage plans a star rating. Much of this rating is based on feedback of current plan members. Five stars is the highest rating, but is not all that common. 3 and 4 star plans are very common. If a plan has a rating lower than 3, it must notify its members and those members can change out of that plan mid-year.
Learn more about Medicare HMO plans reviewing each HMO plan one by one is a tedious chore. Get help from a licensed insurance agency that specializes in Medicare products. A qualified agent can provide important information, such as a plan’s network size and service area. We also go over the Medicare HMO plan’s star rating and history in the marketplace. Most importantly, we can tell you whether your physicians participate in the plan.
Experienced agencies also can help you consider factors specific to you. For example, we review whether the plan your interested in has a built-in Part D drug formulary that includes your medications.
We’d love to be your agent so contact us for help today!
Preferred Provider Organization (PPO) plans:
The term Medicare PPO stands for Preferred Provider Organization. It means that the Medicare insurance company has a network of health providers that have agreed to see the plan’s members at contract negotiated rates. These network providers will coordinate your care.
What is a Medicare PPO?A Medicare PPO is a type of Medicare Advantage plan that you can join as a private alternative to Original Medicare. In a Medicare PPO, you will generally pay lower co-pays if you see providers that are in the network. You are not usually required to choose a primary care physician or get referrals to see specialists. Each plan has its own rules though, so always check the plan’s Summary of Benefits before enrolling.
A Medicare Advantage PPO must provide your A & B benefits to you under the plan. The plan must include an out-of-pocket maximum cap on your spending. This cap protects you against catastrophic spending during a year when you are experiencing higher than normal medical costs.
In 2021, the maximum that any Medicare Advantage plan can set as your out-of-pocket max is $7,550 per calendar year. That means that $7,550 out-of-pocket on hospital and outpatient expenses is the worst case scenario.
Some of the features of Medicare PPOs include:
Medicare PPO plans will generally have lower premiums, but you agree to use a network of doctors to get the best co-pays. You will pay as you go along, so there will be co-pays collected from you at the time of each service. This includes doctor visits, lab-work, hospital stays, surgeries, durable medical equipment, diagnostic imaging, etc. Some people don’t mind this because they prefer a lower monthly premium. It’s completely up to you.
Do I Still Pay for Part B on a Medicare PPO?Yes, you must be enrolled in both Medicare Parts A and B and live in the plan’s service area to be eligible for a Medicare Advantage PPO plan.
Learn more about Medicare PPO plans Medicare PPO plans are just one option you have for your Medicare-related insurance coverage. They are not the same as Medigap plans. The coverage is different so you’ll want to understand both types of plans before you make your choice.
Selecting a plan can be tricky some areas have many choices. You want to ensure that you will have access to the healthcare providers and medications that you require. A licensed agency specializing in Medicare plans can do this research for you and they should do it at no cost (FREE). After you enroll through us, we provide year round customer support to you when you have questions about how your benefits will pay for certain services or claims. Consult a an agent to determine whether a Medicare PPO plan would be suitable for you.
Private Fee-for-Service (PFFS) plans:
Medicare PFFSMedicare PFFS stands for Private-Fee-for Service and is a certain kind of Medicare Advantage plan available in select areas.
What is a Medicare PFFS plan?A PFFS plan is a type of Medicare Advantage plan. It is not a Medicare Supplement – it works differently.
If you join a Medicare PFFS plan, you agree to pay the plan’s premiums as well as co-pays and coinsurance for medical services as outlined in the plan. The thing that makes these plans different from an HMO or PPO is that you are not limited to any certain network of providers.
Instead, you are to present your Medicare PFFS plan ID card to any provider before seeking medical care. Before treating you, the provider must agree to accept the plan’s payment terms and conditions and bill the plan.
Two common features about Medicare PFFS plans are:
A Private Fee-for-service plan is NOT Medicare Supplement insurance. Providers who do not contract with the plan are not required to treat you except in an emergency. This puts the responsibility on your shoulders to discuss with any healthcare providers whether or not they agree to see you and bill the plan.
Learn more about Medicare PFFS plans Because of the rules about how to access providers, it is particularly important to work with a good insurance agent when researching your options. You need to fully understand how, where, and when you can use your coverage so that there are no surprises when you are seeking medical care.
The Modern Medicare Agency has expert licensed insurance agents with a great deal of knowledge about PFFS plans. Ask about PFFS plans in your area today!
Special Needs Plans (SNPs):
Medicare Special Needs PlansMedicare Special Needs Plans (SNPs) are a type of Medicare Advantage plan that provides coordinated care to beneficiaries with specific needs or situation. Like all Advantage plans, Special Needs Plans will have a network, usually either an HMO or a PPO.
These SNPs limit their membership to beneficiaries who have specific illnesses, chronic conditions, or circumstances such as being eligible for both Medicare and Medicaid. The plans must include all of the same services as Original Medicare Parts A and B.
However, Special Needs Plans tailor their plan benefits, network and drug formulary to meet the needs of individuals who have these specific health conditions or circumstances. All Special Needs Plans include a built-in Part D drug plan.
Let’s review some of the types of Special Needs Plans and how they work:
Chronic Illness Special Needs PlanA Medicare Advantage Special Needs Plan based on health conditions is a plan that is specifically designed to provide excellent support for individuals with a chronic illness. For example, the SNP might provide access to a group of providers who specialize in treating these specific illnesses.
These providers work together to coordinate your care. The plan will often assign a care coordinator or case manager to assist you with keeping healthy, managing your health condition and following your provider’s orders. He or she might also help you with accessing community resources or getting the right prescriptions in a timely manner.
The drug formulary that is built into the plan is also likely to offer a robust list of drugs that treat this particular health condition.
To qualify for a chronic illness SNP, you must have one or more of health conditions listed below:
Chronic Illness SNPs vary by county. Insurance companies get to choose where they will offer certain plan designs, so you may or may not be able to find a SNP in your area that specializes in the condition that you have. Check with your Medicare insurance broker to see what is offered.
Institutional Special Needs Plan (ISNP)Medicare beneficiaries who live in an institution, such as an assisted living center, nursing home, or memory care center, may qualify for an Institutional SNP.
These plans are similar to the chronic illness SNP but instead focus on dealing with the provision of coordinated care to someone who is no longer living independently. The beneficiary must be expected to live in the institution for at least 90 days.
Dual Eligible Special Needs Plan (DSNP)Some Medicare beneficiaries also qualify for Medicaid. Medicaid is a federal and state health insurance program for people with low incomes.
When you qualify for both, you can keep your Original Medicare and have Medicaid function as your secondary coverage, or you can enroll in a Dual Eligible Special Needs Plan.
People with full Medicaid can expect to spend little to nothing on deductibles, copays, and coinsurance for Part A and B services provided by the plan. Many plans have a $0 premium because Medicaid pays any plan premium for you. People with partial Medicaid may have to pay some cost-sharing.
Dual Special Needs Plans often also offer rich ancillary benefits. These might include:
Enrolling in a SNPTo qualify for enrollment into a Special Needs Plan, you must live in the plan’s service area and be enrolled in both Medicare Parts A and B. You will continue to pay your Part B premium to Social Security the entire time that you are enrolled in the plan (unless this is covered for you by Medicaid.)
You will also pay any monthly premium that the plan itself charges for the SNP. Finally you will pay the regular cost-sharing expenses, such as deductibles, copays, and coinsurance. These amounts can be found in the plan’s Summary of Benefits, which you should review before joining the plan.
You can enroll in a Medicare Advantage SNP during your Initial Enrollment Period for Medicare or during any Medicare Fall Annual Election Period. Some people may also qualify for Special Enrollment Periods during the year in certain situations. These include:
Have Questions about Medicare Special Needs Plans?Our agency works with a number of Medicare Advantage Special Needs Plans. Give our team a call to see if we can help you find the right SNP for you.
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