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MEDICARE ADVANTAGE PLANS
How much you pay for each visit or service (co-payment or coinsurance). For example, the plan may charge a co-payment, like $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare.
MEDICARE ADVANTAGE PLANS AND OPTIONS
MEDICARE HMO PLANS
Medicare Advantage HMO Plans are the most popular type of Medicare Advantage Plans. These plans are a type of coordinated care in which you will choose a primary care doctor in the network. You usually must get a referral from that doctor before you can see a network specialist.
Medicare HMO plans often have the lowest monthly premiums of the three types of Medicare Advantage programs. This is because they are generally the most restrictive, requiring a primary care physician. Members visit their PCP first to obtain a referral before they can see a specialist.
MEDICARE PPO PPO PLANS
PPO Plans are also also referred to as coordinated care plans. But PPO Plans are gusually more flexible than Medicare HMO plans. Members can see usually see any doctor in the network without a referral. You can also treat outside the network, although you will spend more to do so.
Always check the rules of your specific plan, which can be found in the plan’s Summary of Benefits.
MEDICARE PFFS (PRIVATE FEE-FOR-SERVICE PLANS)
Private-Fee-For-Service Medicare Advantage Plans usually have no network or a very small network. You can see any doctor who will bill the plan as long as they agree to the plan’s terms and conditions up front. This puts the burden on you to ask your providers whether they will accept the plan before you seek medical services. These plans have been phased out in many counties where at least 2 other plan types exist.
OTHER MEDICARE ADVANTAGE PLAN TYPES
Medicare Advantage Plans (MA) and Medicare Advantage Plans With Part D Benefits (MA/PD) plans vary by county. In fact, there are only a certain number of plans offered by each Insurance Company, in each area that they participate in. Across the country there are many areas where there are few to even zero Medicare Advantage Plans available.
Special Needs Plans (SNPs) are available only to Medicare beneficiaries with certain health conditions. The plans are designed to address those health needs with special providers and drug formularies that are most suitable for people with those conditions. Most SNP plans are an HMO format.
Medical Savings Account Plans (MSAs) offer a health savings account alongside the insurance benefits. Medicare itself will put a set amount of funds into your account each year. You may spend those dollars whenever you access qualifying health services. MSA plans are not available in all counties.
NOTE: All Medicare Advantage plans offer their own summary of benefits, and these benefits as well as the plan’s formulary, pharmacy network, provider network, premium and/or co-payments/coinsurance may change on January 1 of each year.
WHEN YOU CAN ENROLL IN A MEDICARE ADVANTAGE PLAN
You can join a Medicare Advantage plan during your 7-month Initial Election Period for Medicare. You can also join or dis-enroll from Medicare Advantage during the Annual Election Period. This occurs in the fall from October 15th – December 7th.
A variety of Special Election Periods exist too. If you qualify, you might be able to join mid-year. A common one is when you move out of state and lose your existing Medicare Advantage plan. Medicare allows you a 63-day window to choose another in your new state. Another SEP occurs if you become eligible for Medicaid or the Part D Extra Help program. People with low incomes have continuous special election periods. This means you can change plans any time of year.
YOU CAN CHOOSE ANY MEDICARE ADVANTYAGE PLAN TAHT IS AVAIILABLE IN YOUR SERVICE AREA
Medicare Advantage programs have service areas. Service Areas are generally plans that are specific to the County you reside in. Remember that you must be enrolled in both Medicare Parts A and B and live in the plans’ service area. You cannot join a plan that does not operate in the county where you live. A licensed health insurance agent can help you determine which plan options exist in your county. He or she will help you work through a checklist of items to see which plan best suits you.
HOW MUCH DO MEDICARE ADVANTAGE PLANS COST?
Your annual out-of-pocket costs in a Medicare Advantage or Medicare Part C Plan depend on:
Whether the plan charges a monthly premium. Some plans have no premium.
Whether the plan pays any of your monthly Medicare Part B premium of $164.90 for 2023 premium. Some plans pay all or part of your Part B premium.
Whether the plan has a yearly deductible or any additional deductibles.
How much you pay for each visit or service (co-payment or coinsurance). For example, the plan may charge a co-payment, like $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare.
The type of health care services you need and how often you get them.
Whether you go to a doctor or supplier who accepts assignment if:
You're in a PPO, PFFS, or MSA plan.
You go out of your plans network.
Whether you follow the plan's rules, like using network providers.
Whether you need extra benefits and if the plan charges for it.
The plan's yearly limit on your out-of-pocket costs for all medical services.
Whether you have Medicaid or get help from your state.
Note: Each year, plans set the amounts they charge for premiums, deductibles, and services. The plan (rather than Medicare) decides how much you pay for the covered services you get. What you pay the plan may change only once a year, on January 1st.
MEDICARE ADVANTAGE PLANS SEND INFORMATION TO THEIR MEMBERS EACH YEAR IN THE FALL
One of the biggest differences between Original Medicare and Medicare Advantage is that there are no guarantees that any Medicare Advantage plan will be available the next year. If it is, and you are okay with your plan, and you want to keep it (Again, as long as it is available) for the next year, you do not have to do anything, you will automatically be enrolled in the same Plan effective January 1st.
If you do not like your plan, you can choose a new plan during the Fall Annual Enrollment Period (AEP). Once you enroll in a new MA or MA/PD plan, your current plan ends at midnight on December 31st and your new plan begins at 12:01 AM on January 1st.
The EOC gives you details about what the plan covers, how much you pay, and more.
ANNUAL NOTICE OF CHANGE LETTER (ANOC)
The ANOC includes any changes in coverage, costs, or service area that will be effective in January.
SUMMARY OF BENEFITS (SOB)
In every Medicare Advantage plan their is a Summary of Benefits Section. You need to read through this section and through the Explanation of Benefits section with a Fine Toothed Comb. This is where you can see exactly how your benefits will be paid, and this is the fine print that the plan hope that you will not read.
NOTE: If you don't receive these important documents, contact your plan.