Medicare Advantage Basics

by MarkG

MEDICARE ADVANTAGE PLANS…WHAT ARE THEY?

Did you know that there are different ways to get your Medicare coverage? When they think of Medicare, many people think of the government program known as Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance). But you may have other Medicare plan options. For example, you may be able to get your Part A and Part B benefits through a private, Medicare-approved insurance company with a Medicare Advantage Plan.

That’s what the Medicare Part C (Medicare Advantage) program is all about: it gives you an alternative way to receive your Original Medicare (Part A and B) coverage. Some Medicare Advantage plans include additional benefits as well – prescription drug coverage, for example, or routine dental services and/or fitness programs. These are just a few examples of additional benefits that some Medicare Advantage plans offer – benefits not included in Original Medicare.

It’s important to know that Original Medicare doesn’t cover prescription drugs in most situations – for example, Medicare Part A and Part B don’t generally cover the medications you might take at home. Most Medicare Advantage plans do include prescription drug coverage – so you can get all your Medicare benefits in one policy.

If you’re looking for a Medicare Advantage Prescription Drug plan (that is, a Medicare Advantage plan with prescription drug coverage), you might want to make sure it covers the prescriptions you take. Each Medicare Advantage Prescription Drug plan has its own formulary (list of covered prescription drugs). The formulary may change at any time; you will receive notice from your plan when necessary.

Since Medicare Advantage plans are available from private companies that contract with Medicare, each plan sets its own premium; some plans come with a premium and others have a $0 premium. It all depends on the state and city you live in.

When you enroll in a Medicare Advantage Plan, you’re still in the Medicare program, and you’re still required to pay your monthly Medicare Part B premium.; however, your Medicare services are covered and administered through a single policy with a private insurance company. The government gives a monthly reimbursement to the company.

There are several types of Medicare Advantage plans, such as Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO)* plans, Private Fee-For-Service (PFFS) plans, and Special Needs Plans (SNPs). Other Medicare Part Advantage plan options include HMO Point-Of-Service (HMO POS) plans and Medical Savings Account (MSA) plans. Depending on where you live, you might not find every type of plan available to you.

What does a Medicare Advantage plan cover?

  • Medicare Advantage plans must cover all the medical and hospital services that Original Medicare covers, except hospice care (Original Medicare covers hospice care even if you’re enrolled in a Medicare Advantage plan).
  • All types of Medicare Advantage plan options cover emergency and urgent care.
  • Medicare Advantage plans may offer additional coverage, such as routine vision and dental services, hearing benefits, or memberships to health and wellness programs.
  • Many plans include Medicare prescription drug coverage, as mentioned above.

How do I qualify for a Medicare Advantage plan?

You can generally qualify for a Medicare Advantage plan if you meet these conditions:

  • You have Medicare Part A and Part B coverage.
  • You live in an area serviced by the Medicare Advantage plan you want to enroll in.
  • You don’t have end-stage renal disease (ESRD – permanent kidney failure requiring dialysis or a kidney transplant), in most cases. There are exceptions, so if you have ESRD and want to get a Medicare Advantage plan, contact the plan you’re considering and ask.

What will a Medicare Advantage plan cost?

The cost of a Medicare Advantage Plan can vary from one plan to another and one location to another. Here are some questions to consider when deciding on a Medicare Advantage plan:

  • Does the plan charge a monthly premium in addition to your Medicare Part B premium?
  • How much will you pay for each service or visit (copayments or coinsurance), both in-network and out-of-network?
  • Does the plan have an annual deductible?
  • What’s the maximum out-of-pocket limit? (Every Medicare Advantage plan has one.)
  • Does this plan have network restrictions? Will you be using network providers or out-of-network providers?
  • Do you have certain physicians and specialists you prefer to keep? Are they in the plan’s network?
  • If the plan covers prescription drugs, are all of your drugs on formulary?
  • Are there any additional benefits in the plan, such as routine vision or dental coverage? Do you need them? What do these benefits cost?

Because the costs and additional benefits vary among plans, you might want to compare Medicare Advantage plans in your area. You can do this by going to Medicare.gov and clicking Find Plans and type in your zip code.

When can I sign up for a Medicare Advantage plan?

There are a few time periods when you can enroll in a Medicare Advantage plan.

  • The Initial Coverage Election Period (ICEP) begins three months immediately before you are entitled to both Medicare Part A and Part B. The ICEP ends either the last day of the month before you have both Part A and Part B or the last day of the Part B Initial Enrollment Period, whichever is later.
    If you’re enrolled in Original Medicare during your Medicare Initial Enrollment Period (IEP), automatically or otherwise, your Initial Coverage Election Period and your Initial Enrollment Period happen at the same time. The Initial Enrollment Period starts three months before the month you turn 65, includes your birth month, and ends three months after that (seven months total). If you didn’t sign up for Original Medicare during the Initial Enrollment Period (if you still have health insurance through an employer or union, for example), your Initial Coverage Election Period is the 3-month period before your Medicare Part B start date. For example, if you enrolled in Medicare Part B during the General Enrollment Period (January 1–March 31), your Part B start date would be July 1, so your Initial Coverage Election Period would be April 1 to June 30.
  • The Annual Enrollment Period (AEP) runs from October 15 to December 7 each year. You can switch from Original Medicare to a Medicare Advantage plan at this time, and make other coverage changes. If you’re already enrolled in a Medicare Advantage plan and want to switch plans, in most cases a good time to do so is during the Annual Election Period.  When you change Medicare plans during the Annual Election Period, your new coverage generally begins on January 1 of the following year.
  • In some cases, you may be able to change Medicare Advantage plans during Special Election Periods (SEPs). Situations that qualify you for an SEP include (but are not limited to) moving to a new address, losing your current coverage, qualifying for other coverage, or changes in your current plan that affect your health benefits. Also, if you have a 5 star plan in your area you can change to that plan.
  • If you’re enrolled in a Medicare Advantage plan and want to switch back to Original Medicare, Part A and Part B, you can do so during the AEP (described above) or during the Medicare Advantage Disenrollment Period, which runs from January 1 to February 14 each year.

Would you like to learn more about Medicare Advantage plans in your area? Ask me about anything else you’d like to know. You can use one of the links below to set aside some time to talk with me by phone, or ask me to email you with more information. Learn more about who I am by clicking my photo or profile below. If you want to start comparing the plans available in your area, click the Find Plans or Compare Plans buttons on this page. If you’re ready to discuss your Medicare needs now, we’d welcome a call from you.

Call 1-800-708-5810, Monday through Saturday, 8AM to 8PM ET. You can also email us at [email protected]

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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