Medicare Advantage
Medicare Advantage, also referred to as Medicare Part C, is a type of health insurance plan that covers the same benefits that are covered under Original Medicare Parts A and B. Instead of having multiple sources of coverage, Part C combines these benefits into one plan for ease of use. If you seek additional coverage, you can chose options that do not fall under Medicare A and B for a higher premium.
WHAT IS MEDICARE ADVANTAGE?
Medicare Part C is an alternative to Original Medicare. Part C pays instead of Medicare Parts A and B, and offers the same coverage as Original Medicare under a single plan. It gives beneficiaries the option to increase their protection with additional coverage options if desired. Under Medicare Parts A and B, beneficiaries are covered for necessities such as preventative care, inpatient and outpatient procedures, medical equipment, and specific types of therapy. If this coverage isn”t sufficient, additional options are available for benefits such as dental, vision, hearing, and prescription coverage through Medicare Advantage plans. If you join a Medicare Advantage Plan, you”ll have all of the same rights and protections that you would have under Original Medicare.
HOW MUCH DOES MEDICARE ADVANTAGE COST?
There is no single set cost of Medicare Advantage because there are a variety of plans to choose from. Each plan offers you different benefits. It is expected that Medicare Advantage plan beneficiaries pay coinsurance, copays, and deductibles and an out-of-pocket maximum. The maximum is the result of Federal Law, and it limits the amount that a beneficiary will spend out of pocket in a calendar year.
Cost can also be determined by your income. Some Medicare Advantage plans are tailored to low-income individuals. These plans often have low or no cost for premiums, deductibles, coinsurance, and copays. Thus, the payment for Medicare Advantage plans can vary significantly.
It”s important to note that Medicare Part C is run through private insurance companies. Medicare will pay the private insurance company a capitation rate owed for coverage equal to Medicare Parts A and B. If there is any remainder, you will pay this as your premium.
PROS AND CONS OF MEDICARE ADVANTAGE
PROS OF MEDICARE ADVANTAGE
Medicare Advantage is a great program for individuals looking for more choices in their insurance coverage. If Medicare Parts A and B don”t cover everything you want in your insurance program, there may be an insurance plan that meets your needs under Medicare Advantage. Many of our clients enroll into Part C because of additional coverages for vision, dental, hearing. There may also be offers for flex cards, part b givebacks, and transportation. In addition, Part C allows for a more concise coverage instead of beneficiaries separately receiving parts A and B. Medicare Advantage plans are managed care plans, which means they manage your costs, coverage, and provider networks so you don”t have to.
CONS OF MEDICARE ADVANTAGE
Medicare advantage plans require beneficiaries to do their research before picking a plan. Below are a few notes to consider when shopping for your coverage.
With Medicare Advantage plans, beneficiaries are required to keep Medicare parts A and B. This means that you will pay both your Original Medicare premium and your part c premium. Keep in mind, some MA plans offer Part B giveback options to lower or eliminate the part b premium.
Aside from this, you cannot supplement your Part C plan with a Medigap plan. If you have any coinsurance, copayments, deductibles, or premiums, you will be required to pay these amounts out of pocket. Some ancillary plans(link) may help pay for out-of-pocket expenses but will only pay for specific services such as hospital visits. Additionally, to some beneficiaries, managed care plans can feel restricting. Referrals and prior authorizations are often required by Medicare Advantage plans, and some beneficiaries choose not to enroll because of the lack of flexibility.
MEDICARE ADVANTAGE PLAN TYPES
HMO PLAN
An HMO plan is a type of Medicare Advantage Plan that provides coverage exclusively from providers or hospitals in the plan”s network. This excludes emergency care, out-of-area urgent care, or temporary out-of-area dialysis. A network is a group of providers, hospitals, and medical facilities that contract with a plan to administer your services. Most HMO plans also require you to get a referral from your primary care provider (PCP) in order to receive care from a specialist. This ensures that your care is coordinated.
Some HMO plans, known as HMO Point-of-Service (HMO-POS) plans, offer an out-of-network option for some covered items or services. However, just like a regular HMO, if you receive care outside of the network without a prior authorization, you may have to pay the full cost of your services. In most cases, you will also need to choose a primary care physician (pcp). Preventative services, like yearly flu shots or annual mammograms, don”t typically require a referral. If your provider leaves the plan”s network, you will be notified. You will need to choose a new provider who is considered in-network. If you decide to enroll in an HMO plan and you need prescription drug coverage, you will need to join a plan that includes Part D. If you join an HMO plan that excludes drug coverage, will not be able to join a standalone part D plan.
PPO PLAN
A Preferred Provider Organization (PPO) plan is a Medicare Advantage Plan that has network doctors, specialists, hospitals, and other health care providers you can use. However, you can also use out-of-network providers for covered services. Keep in mind that using out-of-network providers usually results in a higher cost. The provider also must agree to treat you and it is required that they have not opted out of Medicare (for Medicare Part A and Part B items and services). Before you get services from an out-of-network provider, you will need to ask for an organization determination of coverage from your plan. The purpose of this document is to state that the services are medically necessary, and that they are covered by your plan before you receive them. It is important to note that beneficiaries with a PPO plan are always covered for emergency services and urgent care. If you decide to enroll in an PPO plan and you need prescription drug coverage, you will need to join a plan that includes Part D. If you join an PPO plan that excludes drug coverage, will not be able to join a standalone part D plan.
SNP PLAN
Special Needs Plans offer tailored coverage for beneficiaries in special circumstances. SNP plans design their benefits and networks to meet the exact needs of the beneficiaries and cover the same benefits and services as Parts A and B. They also offer additional benefits. For example, if a beneficiary has a chronic condition, like diabetes or a degenerative brain disease such as Alzheimer”s, a special needs plan may cover items or services such as compression stockings or additional days in a nursing facility. SNPs are required to include prescription drug coverage as a part of their benefits.
There are 3 types of SNP plans. Dual Eligible Special Needs Plans (D-SNP) offer coverage for beneficiaries who are entitled to both Medicare and Medicaid. They contract with both to provide additional benefits at a lower cost. Chronic Condition Special Needs Plans (C-SNP) offer coverage specifically for beneficiaries who have a chronic condition. This can include diagnoses such as heart failure, diabetes, cancer, degenerative brain diseases, COPD and more. Institutional Special Needs Plans (I-SNP) offer coverage for beneficiaries who live in a facility or require additional care which can only be provided by a facility. These facilities can include but are not limited to skilled nursing facilities (SNF’s), psychiatric hospitals, and nursing homes.
Keep in mind, beneficiaries can only join a Special Needs Plan as long as they continue to meet the chronic, dual, or institutional conditions that the plan requires for eligibility.
PRIVATE FEE-FOR-SERVICE (PFFS) PLANS
A Private Fee-for-Service (PFFS) plan is another kind of Medicare Advantage Plan offered by a private health insurance company. A PFFS plan isn”t the same as Original Medicare or Medicare Supplement Insurance (Medigap). Per CMS guidelines, “You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan”s payment terms, agrees to treat you, and hasn”t opted out of Medicare (for Medicare Part A and Part B items and services).” (Centers for Medicare & Medicaid Services, 2022) If you join a PFFS plan that has a network, you will be able to visit providers who have already agreed to work with plan members. You also have the option to choose providers who are considered out of network. These providers are required to accept the plan”s terms, and similar to a PPO plan, you will pay more for services from out-of-network providers. If your provider has agreed to the plan’s terms and conditions, your provider must follow their rules. If you decide to see a provider who has not accepted the plans terms, the PFFS is only required to cover emergency services, urgent care, and out of area dialysis. PFFS plans have a different billing structure than other types of Medicare Advantage plans. If you see a provider who accepts the plans terms and has agreed to service you, they can only bill you for cost sharing that has already been approved by your plan. They are required bill the plan for any services that are considered covered. At the time of service, beneficiaries are only required to pay the allowed copayment or coinsurance. Then the provider will bill the plan for covered services. PFFS plans sometimes allow “balance billing” which means that a doctor or other provider can charge up to 15% more than the amount that Original Medicare pays. This is important to understand because the provider can bill you for that amount. If you choose a plan that allows balance billing, you may have to pay both the difference between what the provider charged and the amount Medicare pays, and the copay or coinsurance that was determined by the plan. If you decide to enroll in an PFFS plan and you need prescription drug coverage, you will need to join a plan that includes Part D. If you join an PFFS plan that excludes drug coverage, will not be able to join a standalone part D plan.
How it works with Medicare A+B
MEDICARE ADVANTAGE AND ORIGINAL MEDICARE
Medicare beneficiaries often believe that Medicare advantage plans supplement their Medicare coverage, but this is not the case. Medicare Advantage plans pay instead of Medicare A and B. Any covered services will be submitted to the Medicare Advantage plan for payment. If there is a left-over patient responsibility such as a coinsurance, copay, or deductible, this would be the beneficiary”s responsibility to pay. Medicare parts a and b do not pay before or after the Medicare Advantage plan.
How it works with other types of coverage
MEDICARE ADVANTAGE AND OTHER COVERAGES
If you have another type of coverage and are considering joining a Medicare Advantage plan, you will need to talk to your benefits administrator about their policies. You will need to have this discussion before you make any changes because joining a Medicare Advantage Plan might cause you to lose your employer or union coverage. This would not only apply to yourself, but would also apply to your spouse and any dependents you may have. Keep in mind, once you join a Medicare Advantage plan, you may not be able to re-enroll into your previous coverage. In some cases, you may be able to continue using your employer or union coverage along with the Medicare Advantage Plan. Your employer or union may offer a Medicare Advantage plan that they sponsor. This is also know as a retiree plan. Talk to your benefits administrator to find out what is offered to you.
