Medicare Advantage Plans, also known as Part C, are offered by approved private companies and are similar to an HMO or PPO. A Medicare Advantage Plan provides full Part A and Part B coverage which is your Hospital Insurance and Medical Insurance. All Medicare Advantage Plans also cover emergency and urgent care. Medicare Advantage Insurance must cover all services that Original Medicare covers excluding hospice care.
Some Medicare Advantage Plans have extra coverage like vision, hearing, dental or wellness programs, and most have Medicare Part D Prescription Drug Coverage. You must pay your Part B premium and another monthly premium for other services. Medicare pays a flat rate to the companies offering Medicare Advantage Plans and these companies are required to follow rules set by Medicare. They can charge you differently for out-of pocket expenses and can have different rules for how you receive services.
There are several different types of Medicare Advantage Plans. The most common include: Health Maintenance Organization Plans (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans (PFFS) and Special Needs Plans (SNP). There are also less common plans including HMO Point of Service Plans and Medical Savings Account Plans.
In a regular HMO, your care usually comes from the plan’s network (excluding emergency care). HMO plans usually cover prescription drugs but not always. You will most likely have to choose a primary care doctor in an HMO and will probably need a referral from that doctor to see a specialist. If your primary doctor leaves the plan you will need to choose a new doctor. You should also make sure you know the rules of the plan. In some cases, you will need to prior approval from your provider to get care outside of the network.
In a PPO, you can get your care from any doctor or hospital. PPOs can have a network but you can go outside that network if you are willing to pay a higher cost. Most PPOs cover prescription drugs. You will not need to choose a primary care physician or get a referral to see a specialist. You should note that there are Regional PPOs and Local PPOs. Regional PPOs work in one of the 26 Medicare regions while Local PPOs serve the counties the PPO Plan chooses.
A PFFS plan allows you to go to any Medicare-approved physician. Hospitals that accept the plans payment terms are also allowed, however, not all hospitals or providers will accept the terms. Some PFFS plans have networks; if you join such a network you can use any of their providers. These plans sometimes offer prescription drug coverage. If your plan doesn’t cover prescriptions you can join a Medicare Prescription Drug Plan (a Part D plan). You will not need to choose a primary doctor or get a referral for a specialist. You should be aware that a PFFS plan decides how much you pay for a given service and doctors/hospitals may decide to not treat you, even if you have been a patient before. You may also pay more if you choose an out of network doctor if your PFFS plan has a network. In an emergency, hospitals and doctors must treat you.
SNP plans require you to get care from doctors and hospitals in your plan’s network, except for emergency care. In an SNP all prescription drugs are provided for under a Part D plan. You will need to choose a primary doctor and you will most likely need a referral for most specialists. These plans are limited to people who live in institutions like nursing homes, are eligible for Medicare and Medicaid, or have specific chronic conditions (including HIV/AIDS, ESRD or diabetes).
How do you Qualify?
To qualify for a Medicare Advantage Plan you need to qualify for Medicare and have Medicare Part A and Part B. You will have to pay the monthly Part B Premium to Medicare. You will probably have to pay a monthly premium to your Medicare plan as well.
If you get a Medicare Advantage Plan, and have a Medigap/Medicare Supplemental Plan, the Medigap/Medicare Supplemental Plan will not work; it won’t pay deductibles, copayments, or other costs. You may want to drop any Medigap/Medicare Supplemental Plan—although legally you do not have to.
You must also reside in the service area of the plan you select. If you have End-Stage Renal Disease you cannot join a Medicare Advantage Plan except under certain circumstances.
If you have other coverage through an employer or union, you should check with them before getting a Medicare Advantage Plan. A Medicare Advantage Plan might cause you to lose such coverage. Sometimes, however, you can use Union or Employer coverage with a Medicare Advantage Plan. You need to talk to your employer or union before getting a Medicare Advantage Plan.
How much does it cost?
What you pay for a Medicare Advantage Plan will vary. There are some questions you need to ask to determine what you pay.
Where/how do you get it?
You can join a Medicare Advantage Plan by completing a paper application, calling the plan, or enrolling on a plan’s website. You will need to provide your Medicare number when you enroll and know when your Part A and B Medicare Coverage began.
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