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Medicare Advantage

Medicare Advantage (MA) Plans are health plan options that are approved by Medicare and run by private companies.

They are part of the Medicare program and are sometimes called “Part C.” Medicare Advantage Plans provide the same services as Medicare and may offer extra benefits that Medicare doesn’t cover, such as vision or dental services. Some Medicare Advantage plans include prescription drug coverage. Members may have to pay an additional monthly premium for the extra benefits. The plan may have special rules that its member need to follow.

How do Medicare Advantage Plans work?

In most Medicare Advantage Plans, members generally get all their Medicare-covered health care through that plan. Some plans also include Medicare prescription drug coverage. Medicare pays a set amount of money for a person’s care every month to these private health plans, whether or not the member uses services.

What are the Costs of Medicare Advantage Plans?

Most people enrolled in a Medicare Advantage Plan must still pay their Part B premium. Members may also pay an additional monthly premium to the plan. Members also have cost-sharing in Medicare Advantage Plans. These could be in the form of copayments or coinsurance. Cost-sharing in a Medicare Advantage Plan may be different from those in Original Medicare. Because of this, it’s important that people review plan materials carefully for details about copayments and coinsurance for the services they get.

What are the Benefits of Medicare Advantage Plans?

People who join a Medicare Advantage Plan are still in the Medicare program. They still have Medicare rights and protections. Through the plan, they still get all their regular Medicare-covered services that are offered under Part A and Part B. They may get prescription drug coverage through the plan. Extra benefits could be offered. These might include coverage for vision, hearing, dental and/or health and wellness programs.

What Kind of Medicare Advantage Plans Are There?

There are currently five main types of Medicare Advantage Plans

  1. Medicare Health Maintenance Organizations (HMO) Plans.These are managed care plans that cover all Part A and B services and may provide extra services. You can generally only go to doctors, specialists or hospitals that are part of the plan’s network, except in an emergency.
  2. Local Medicare Preferred Provider Organizations (PPO) Plans.These plans are similar to HMO plans but members can see any doctor or provider that accepts Medicare. Members do not need a referral to see a specialist. Going to a provider who isn’t part of the plan’s network will usually cost more.
  3. Medicare Special Needs Plans (SNP). Membership in these plans is limited to certain groups of people, such as those in some institutions (like a nursing home), eligible for both Medicare and Medicaid or with certain chronic or disabling conditions.
  4. Medicare Private Fee-for-Service (PFFS) Plans.Members in PFFS can go to any provider that accepts the plan’s terms and conditions of payment. Extra benefits may be included in these plans. The private company decides how much it will pay and how much member pay for services.
  5. Medicare Medical Savings Account (MSA) Plans.

Who Can Join?

Medicare Advantage Plans are available to most people with Medicare. To be eligible to join a Medicare Advantage Plan, a person must:

  • Live in the plan’s geographic service area or continuation area
  • Be enrolled in Medicare Part A and Part B
  • Agree to provide the necessary information to the plan,
  • Agree to follow the plan’s rules, and
  • Belong to only one Medicare Advantage plan at a time.

When Can People Join?

People can join a Medicare Advantage Plan

  • When they first become eligible for Medicare,
  • During the Medicare fall open enrollment period ,
  • During the Medicare Advantage Open Enrollment Period, or
  • In certain special situations that provide a Special Enrollment Period.

Medicare Fall Open Enrollment The Medicare Fall Open Enrollment occurs every year from November 15 – December 31. People can make changes in their plan enrollment. If they do not want to stay in their current plan, they can enroll into a different Advantage Plan or return to Original Medicare. Their new plan will start the following January 1.

This is the key time for individuals to review their health care and drug coverage and make changes for the following year, if they choose.

Medicare Advantage Open Enrollment Period People also have the opportunity to change how they get their Medicare benefits during the Medicare Advantage Open Enrollment Period (OEP) each year. During this OEP they can join a new plan, switch plans, or return to Original Medicare. This occurs from January 1 through March 31 every year.

Changes made during this period will be effective the first day of the month after the plan gets the person’s enrollment form.

Special Enrollment Periods There are Special Enrollment Periods for special circumstances. A person can make changes if:

  • If he or she moves out of the service area,
  • If he or she qualifies for extra help to pay for Medicare prescription drug coverage, or
  • If the plan decides to leave the Medicare program or reduce its service area at the end of the year.

Special Trial Rights

Those who join Medicare Advantage are entitled to a trial period that allows them to try the plan out and switch back to Original Medicare if they are dissatisfied.

You are eligible for this trial period if you:

  • Joined an MA plan when first eligible for Medicare at age 65, or
  • Were in Original Medicare, enrolled in an MA plan for the first time, and dropped a Medigap policy.

The trial right allows you to disenroll from the MA plan during the first 12 months to join Original Medicare. You also have a guaranteed issue opportunity to purchase a Medigap policy.

Read the next page about Choosing a Medicare Advantage Plan