Medicare Advantage Part C
Basics of Medicare Advantage
Basics of Medicare Advantage
Medicare Advantage Part C is the second option that someone will have to choose from when they are eligible for Medicare. This option is provided by private insurance companies and not by the federal government. They must provide the same if not better coverage as that of Original Medicare.
Most of the plans will give you some additional benefits not provided by the federal government and will vary by plan. You cannot have both Medicare Part A and B and a Medicare Advantage plan; you must choose one or the other.
Understanding that Original Medicare is offered by the federal government and the Medicare Advantage plan is offered by a private insurance company is the key to understanding Medicare and becoming an expert.
When someone enrolls into a Medicare Advantage plan, they are no longer enrolled in Original Medicare. The private insurance company now manages the healthcare and will send the individual their own card to use for hospital and medical services. This will replace the red, white, and blue Medicare card.
Medicare Advantage Benefits
Medicare Advantage plans can offer some incredible benefits. The first benefit that makes a Medicare Advantage plan attractive is that the individual will have a calendar year out-of-pocket limit for their hospital and medical expenses. That is something that Original Medicare does not provide to you as a benefit.
Another incredible benefit with a Medicare Advantage plan is the convenience of having an all-in-one plan. Most Medicare Advantage plans on the market will include hospital, medical, and the individual’s prescription drug coverage, all with just one card to carry around with them.
Medicare Advantage plans will offer some incredible additional benefits that Original Medicare does not offer like dental, vision, hearing, gym memberships, transportation, meals, and over-the-counter benefits.
HMO, HMO-POS, PPO, RPPO, PFFS, MSA, SNP
In HMO network plans, the individual normally will be required to get their care and services from certain doctors and hospitals that are contracted within that plan’s network.
The individual will normally be required to select a primary care physician (PCP) within the plan’s network who will help to coordinate their care. If they do not have a primary care physician or do not select one at the time of enrollment, one will typically be assigned to them by the plan.
Most HMO plans will require the individual to get a referral from their primary care physician (PCP) to see a specialist.
Under an HMO network plan, the individual will typically be responsible for all costs if they see a provider outside of the network. Certain exceptions would be if they needed emergency care or dialysis treatments outside of the plan’s network.
Most HMO plans will require prior approval for certain services when they are needed.
In HMO-POS network plans, the individual will have more freedom and flexibility with their HMO Medicare Advantage plan. Think of an HMO-POS plan as an HMO plan that allows someone to see out-of-the-network providers for certain or all benefits at a higher cost.
They will typically have separate out-of-pocket limits for in-network and out-of-network services.
These plans will typically have a higher in-network maximum than your traditional HMO plan because the individual will have the benefit of going out-of-network.
The out-of-network provider that the individual might want to see is not required to accept the plan’s terms and conditions of payment. They must make sure before they see the provider that they agree to the terms and conditions of payment from their Medicare Advantage plan, or they may be responsible for all costs.
The HMO-POS plan will normally have to follow the same rules as an HMO and be required to select a primary care physician (PCP) within the plan’s network who will help to coordinate their care.
A benefit of an HMO-POS plan is that the individual may not be required by the plan to get a referral to see a specialist. Most HMO-POS plans will require prior approval for certain services when they are needed.
In PPO network plans, they are offered as either a Local PPO or Regional PPO. The local PPO is the most offered Medicare Advantage plan that you will see available in the individual’s area.
The PPO network plan has an established network of doctors and hospitals in the person’s local area. They will typically pay less out-of-pocket if they use the providers in the plan’s network. They will have separate out-of-pocket limits for in-network and out-of-network services.
In PPO network plans, the individual can go out-of-network and would simply log on to the carrier site and search for a PPO provider at generally a higher cost to them.
This type of plan is great if someone is traveling because they will access to out-of-network providers. They must still check with that provider to make sure they agree to the terms and conditions of payment from their Medicare Advantage plan.
In most cases, they will be fine, but the provider is not required to take the PPO plan just because they take Medicare. In PPO network plans, the individual typically is not required to select a primary care physician (PCP), and they do not need to get a referral to see a specialist. Most PPO network plans will require prior approval for certain services when they are needed.
In RPPO network plans, the in-network will consist of a region instead of a local area. These plans were originally designed for those that lived in rural areas to have access to a region and not limited to just one state like that of a standard PPO.
Medicare set up 26 regions that comprise of one or more states that the individual will have in-network access to get their healthcare.
There may only be one or two RPPO plans offered in a given zip code. In RPPO network plans, the individual can go out-of-network to anyone that accepts the plan at generally a higher cost to them and will follow the same rules and guidelines of a Local PPO. They will typically have separate out-of-pocket limits for in-network and out-of-network services.
In RPPO network plans, the individual is typically not required to select a primary care physician (PCP) and does not need to get a referral to see a specialist. Most RPPO network plans will require prior approval for certain services when they are needed.
In PFFS plans, they are different in many ways than any of the other Medicare Advantage plans. These types of plans may or may not have a network. To better understand a PFFS plan is to realize that Original Medicare operates on the basis as a private fee-for-service.
In PFFS plans, the individual can go to any Medicare-approved provider if they agree to the terms and conditions of payment from the Medicare Advantage plan.
In most cases, the individual will be fine, but they are not required to take the PFFS plan just because they take Medicare. In PFFS plans, the individual does not need to select a primary care physician (PCP), and they do not need to get a referral to see a specialist.
PFFS plans are not prevalent, and there may not be one available in the individual’s zip code. If one is offered, the individual will typically see that it will costs sometimes more than $100 a month to enroll in the plan. The benefit to a PFFS plan is that the individual will have an out-of-pocket limit to their healthcare.
In MSA plans, they are like Health Savings Account (HSA) plans available outside of Medicare. These types of plans are a private-fee-for service, so the individual can go to any Medicare-approved provider.
In MSA plans, the individual does not need to select a primary care physician (PCP), and they do not need to get a referral to see a specialist. In MSA plans, they will incorporate a high-deductible insurance plan with a medical savings account (MSA) that the individual can use to pay for their health care costs.
The individual is responsible for all costs up to the annual deductible. The MSA plan will deposit a certain dollar amount into the individual’s savings account that they can use to pay for their health care costs before they meet the annual deductible. Any money not used in the medical saving account will roll over to the following calendar year.
In MSA plans, they do not offer prescription coverage. This is one of the only Medicare Advantage plans that the individual can purchase a standalone PDP prescription drug plan.
With an MSA plan, the company is not setting up a network but just coordinates the billing with Medicare after the individual has met their annual deductible for that year. The only company that currently offers this plan is Lasso Healthcare.
These types of plans will only be available to the individual who is Medicare eligible and meets the following requirements because the plan’s benefits are designed to meet the specific needs of that individual.
1. D-SNP- Dual-eligible for Medicare and Medicaid because of low income or resources.
2. I-SNP- Institutionalized in a nursing home or assisted living facility.
3. C-SNP- Serious chronic or disabling condition.
SNP plans generally require that the individual gets services from doctors and hospitals that participate in the SNP network. The network will contract with specialists that are experts in the disease or condition that reflects that individual.
The individual will normally be required to select a primary care physician (PCP) within the plan’s network who will help to coordinate their care, and most will require them to get a referral to see a specialist.
These types of plans get more money from the federal government than the average “benchmark” of $900 a month because they will typically require more out-of-pocket expenses for the individual’s healthcare needs.
If the individual has a disabling condition such as chronic heart failure, cancer, diabetes, End Stage Renal Disease (ESRD), HIV, or dementia, they should explore this type of Medicare Advantage plan.
An individual can enroll in this type of plan any time during the year if they meet the requirements. If they are currently enrolled in an SNP plan, they can switch once during each of the first three calendar quarters of the year.
Medicare Advantage Enrollment Periods
There are only certain times during the year that someone can either enroll into or switch a Medicare Advantage plan.
An incredible benefit to Medicare Advantage plans is that the individual never needs to medically qualify to join a plan. No matter what their health condition, if they are eligible for Medicare, they can enroll in a Medicare Advantage plan.
There are only two requirements that someone must meet to enroll in a Medicare Advantage plan.
1. Must be enrolled in Medicare Part A and B.
2. Must have a valid enrollment period to join the Medicare Advantage plan.
The Initial Coverage Enrollment Period (ICEP) is the first time someone can choose a Medicare Advantage plan instead of Original Medicare Part A and B.
If someone is turning 65 and taking their Medicare Part A and B for the first time, their 7-Month Initial Enrollment Period (IEP) and their Initial Coverage Enrollment Period (ICEP) to enroll into a Medicare Advantage will be the same.
If someone was already eligible for Medicare Part A and B because of a disability and they are turning 65, they will get an Initial Coverage Enrollment Period (ICEP).
If someone received their Medicare Part A and B prior to the age of 65 due to a disability, they would also be eligible for an Initial Coverage Enrollment Period (ICEP) after they have received SSDI benefits for 24 months.
If someone has delayed their Medicare and is now taking it for the first time, whether it be for a Special Enrollment Period (SEP) or General Enrollment Period (GEP), their Initial Coverage Enrollment Period (ICEP) will start 3 months before their Medicare Part B effective date.
The Medicare Open Enrollment Period (OEP) will always run from October 15th through December 7th. During this time, the individual can join a Medicare Advantage plan for the first time or make changes to their current Medicare Advantage plan for the next calendar year.
The individual will need to make their selections by December 7th. Their coverage will take effect on January 1st. During the Medicare Open Enrollment Period (OEP), the individual can make these changes:
- Change to a Medicare Advantage plan from Original Medicare.
- Change to Original Medicare from a Medicare Advantage plan.
- Change from one Medicare Advantage plan to another regardless of if they have drug coverage.
- Enroll or drop a standalone PDP prescription plan.
If someone would like to enroll in a Medicare Advantage plan during this time of the year, here are the only two requirements:
- The individual must be enrolled in both Medicare Part A and B.
- They must live within the plan’s service area (network).
If the individual’s current Medicare Advantage plan or standalone PDP prescription drug plan is still available in their area and they do not want to make any changes during the Medicare Open Enrollment Period (OEP), it will auto-renew for the next calendar year at midnight of December 7th.
The Medicare Advantage Open Enrollment Period is only for people that are already enrolled in a Medicare Advantage plan with or without drug coverage.
This period is set aside for those that would like to still make some changes to their current Medicare Advantage plan.
During the Medicare Advantage Open Enrollment Period (OEP), the individual can make these changes:
- Change one time to a different Medicare Advantage plan with or without drug coverage.
- Cancel their Medicare Advantage plan and return to Original Medicare.
- Enroll in a standalone PDP prescription drug plan which will cancel their Medicare Advantage plan and return them to Original Medicare.
No changes can be made to their Medicare Advantage plan after the March 31st midnight deadline until that calendar year’s Medicare Open Enrollment Period (OEP).
The Medicare Special Enrollment Period (SEP) is if the individual delayed their Medicare Part A and/or B coverage during their 7-Month Initial Enrollment Period (IEP) when they turned 65.
If someone is enrolling into their Medicare Part B for the first time, they will have an Initial Coverage Election Period (ICEP) that will start 3 months before their Medicare Part B effective date.
They may also be eligible to receive a 63-day Medicare Special Enrollment Period (SEP) after involuntary loss of coverage for their Medicare Advantage plan or standalone PDP prescription drug plan.
If someone’s Medicare Advantage plan is no longer servicing the area or they moved out of the coverage area, they will be eligible for a 63-day SEP. The individual will have 63 days to enroll in another Medicare Advantage plan.
If someone has a standalone PDP prescription drug plan and moves out of the coverage area, they will be eligible for a 63-day SEP. They can enroll into a standalone PDP prescription drug plan that will service the new area even though they may be outside of the Medicare Open Enrollment Period (OEP).
There are very few Medicare Advantage plans that achieve a 5-star rating since the rating was first introduced in 2007. The Centers for Medicare and Medicaid Services (CMS) rates Medicare Advantage plans on a 5-star system based on the quality of care and customer service.
If a 5-star plan is available in the individual’s area, they will have a one-time opportunity to enroll into that plan anytime during the calendar year for any reason.
This can be an incredible opportunity for someone that is outside of their Initial Coverage Enrollment Period (ICEP) and no longer in the Medicare Advantage Open Enrollment Period.
These plans will continue to market themselves throughout the calendar year because anyone that is eligible for Medicare can enroll in one.
