Medicare Advantage

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 A and B and may offer extra benefits that Medicare doesn’t cover, such as vision or dental services. Some Medicare Advantage plans include prescription drug coverage (Part D). 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 the plan. Some plans also include Medicare prescription drug coverage (Part D). 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. The plan is then responsible for all aspects of care from proof of coverage, processing of claims, payment of claims, determination of medical necessity, explanation of benefits, and statements.

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 co-payments 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 co payments and co-insurance for the services they get. Plans set an annual out-of-pocket limit that is approved by Medicare. If a person reaches their out-of-pocket limit then the plan pays at 100%

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. Extra benefits could be offered. These might include coverage for vision, hearing, dental and/or health and wellness programs. Enrollments in a Medicare Advantage Plans is available to most people with Medicare. These plans provide guaranteed protection high out-of-pocket expenses.

What Kind of Medicare Advantage Plans Are There?

There are currently four main types of Medicare Advantage Plans:

  1. Medicare Health Maintenance Organizations (HMO) Plans – HMO have their own network of doctors, hospital, and other health care providers that agree to accept payment at a certain level for any services that they provide. They tend have lower monthly premiums, co-insurance, and co-payments which makes them more affordable. With a HMO, you must chose a primary care provider from a list of local health care providers. If you are in need of a specialist, you first need to see your primary care provider and if needed, they will provide a referral within the HMO network. HMO Point of Service (HMOPOS) Plans is a HMO Plan that may allow you to get some services out-of-network for a higher cost.
  2. Local Medicare Preferred Provider Organizations (PPO) Plans – A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network . You pay more if you use doctors, hospitals, and providers outside of the network.
  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. For more eligibility requirements click here.  Enrollees must get their care and services from doctors and other health care providers or hospital within the plans network.
  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 and agrees to treat you, not all providers will. If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also chose a out of network provider who accepts the plans terms, but you may pay more. Extra benefits may be included in these plans. The private company decides how much it will pay and how much member pay for services.

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 annual enrollment period (October 15-December 7), or
  • In certain special situations that provide a Special Enrollment Period.

Medicare Annual  Enrollment Period

The Medicare Fall Open Enrollment occurs every year from October 15 – December 7. 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 Disenrollment Period 

You can switch from your Medicare Advantage Plan to Original Medicare (Part A and B) during Medicare Advantage Disenrollment Period (MADP). You can only make this coverage change if you have a Medicare Advantage Plan. The MADP occurs every year from January 1 to February 14. If you have a Medicare Advantage Plan you will be able to switch to Original Medicare with or without a stand-alone prescription drug plan (Part D).

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 dis-enroll 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 section about Choosing a Medicare Advantage Plan.