Medicare Advantage Plan

What is a Medicare Advantage Plan?

Another way to get your Medicare coverage is through Medicare Advantage Plans which is sometimes called "Part C" or "MA Plans". Offered by Medicare-approved private companies which also follow rules set by Medicare. 

There are different types of Medicare Advantage Plans;

• Health Maintenance Organization (HMO) Plans
• Preferred Provider Organization (PPO) Plans
• Private Fee-for-Service (PFFS) Plans
• Special Needs Plans (SNPs)
• HMO Point-of-Service (HMOPOS) Plans
• Medical Savings Account (MSA) Plans

Medical Savings Account (MSA) Plans:

These plans combine a high-deductible health plan with a bank account that the plan selects. The plan deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year. MSA Plans don't offer Medicare drug coverage, if you want drug coverage, you have to join a Medicare Prescription Drug  Plan.

Medicare Advantage Plans cover almost all Medicare Part A and Part B benefits. However, if you're in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new benefits and some costs for clinical research studies. 

Most Medicare Advantage Plans offer coverage for things that aren't covered by Original Medicare, like vision, hearing, dental and wellness programs. Plans can tailor their benefit packages to offer these new benefits to certain chronically ill enrollees. These will give benefits customized to treat those conditions.

Medicare pays a fixed amount for your coverage each months to the companies offering Medicare Advantage plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services. These rules can change each year. Remember, you have the option each year to keep your current plan, choose a different plan or switch to Original Medicare. 

If you're in a Medicare Advantage Plan, review the "Annual  Notice of Change" (ANOC)  and "Evidence of Coverage (EOC) from your plan each year.

• THE ANOC:  Includes any changes in coverage, costs, service area and more that will be effective starting in January
• THE EOC:  Gives you details about what plan covers, how much you pay and more. 

What should I know about Medicare Advantage Plans?

Who can join?

In order to join a Medicare Advantage Plan, you must meet these following conditions;

• You have Medicare Part A and Part B
• You live in the plan's service area
• You don't have End-Stage Renal Disease

You can only join or leave a Medicare Advantage Plan at certain times during the year. Each year, Medicare Advantage Plan choose to leave Medicare or make changes to the services they cover and what you pay. 

What if I have other coverage?

Talk to your employer, union or other benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, it might cause you to lose your employer or union coverage for yourself, your spouse and dependents and you won't be able to get it back. But at some, employer or union may also offer a Medicare Advantage retiree health plan that they sponsor. 

What if I have a Medicare Supplement Insurance (Medigap) policy?

You can't enroll in a Medicare Supplement Insurance policy while you're in a Medicare Advantage Plan. You can't use it to pay for any expenses you have under a Medicare Advantage Plan. 

What if I have End-Stage Renal Disease (ESRD)?

If you ave End-Stage Renal Disease (ESRD), you can only join a Medicare Advantage Plan in certain situations;

• If you're already in a Medicare Advantage Plan when you develop ESRD, you can stay in your plan or you won't be able to join another Medicare Advantage Plan offered by the same company
• If you're in a Medicare Advantage Plan and the plan leaves Medicare or no longer provides coverage in your are, you have a one-time right to join another Medicare Advantage Plan.
• If you have an employer or union health plan through a company that offers one or more Medicare Advantage Plan(s), you won't be able to join one of that company's Medicare Advantage Plan.
• If you're medically determined to no longer have ESRD, you won't be able to join a Medicare Advantage Plan.
• You won't be able to join a Medicare Special Needs Plan (SNP) that covers people with ESRD if one is available in your area.

How do I know what's covered?

You can get a decision from your plan to see if a service, drug or supply is covered. You can also find out how much you'll have to pay. This is called an "organization determination". 

You, your representative or your doctor can ask an organization determination. You also have the option to ask for a fast decision, based on your health needs.

If a plan provider refers you for a service or to a provider outside the network but doesn't get an organization determination in advance, this is called "plan directed care". In most cases, you won't have to pay more than the plan's usual cost-sharing.