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MEDICARE PLANS

What is MEDICARE ADVANTAGE?

A Medicare Advantage Plan is health insurance for the elderly 65 and over, as well as those who have been disabled for at least two years and receive SSDI. You can obtain health care through either Original Medicare or a Medicare Advantage Plan (usually an HMO or PPO).

Medicare Advantage Plans are an additional option for getting Medicare Part A and Part B coverage. Medicare Advantage Plans, often known as “Part C” or “MA Plans,” are provided by Medicare-approved private organizations that must adhere to Medicare requirements. The majority of Medicare Advantage Plans provide medication coverage (Part D). In most circumstances, you must use health-care providers who are part of the plan’s network. These plans restrict your out-of-pocket expenses for covered services each year. Some plans provide non-emergency coverage outside of the network, albeit at a greater cost. Remember that you must utilize your Medicare Advantage Plan’s card to obtain Medicare-covered services.disabled

This implies that it helps pay for health-care expenses that Original Medicare does not cover, such as copayments, coinsurance, and deductibles. These are Medicare coverage “gaps.” If you have both Original Medicare and a Medigap coverage, Medicare will pay a portion of the Medicare-approved amounts for covered health care expenditures. Then your Medigap coverage kicks in. A Medigap policy differs from a Medicare Advantage Plan (such as an HMO or PPO) in that such plans provide access to Medicare benefits, but a Medigap policy merely replaces the expenses of your Original Medicare coverage. Medicare does not cover any of the expenses of a Medigap coverage.

*Plans F and G also offer a high-deductible plan in some states. With this option, you must pay for Medicare-covered costs (coinsurance, copayments, and deductibles) up to the deductible amount of $2,370 in 2021 before your policy pays anything. (You can’t buy Plans C and F if you were new to Medicare on or after January 1, 2020. See previous page for more information.)

**For Plans K and L, after you meet your out-of-pocket yearly limit and your yearly Part B deductible ($203 in 2021), the Medigap plan pays 100% of covered services for the rest of the calendar year.

***Plan N pays 100% of the Part B coinsurance. You must pay a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.

The source: Medicare & You 2022 is The official Medicare guidebook of the United States government

Keep your red, white, and blue Medicare cards secure since you may need to utilize them for some services. You'll also need it if you ever return to Original Medicare. The most prevalent forms of Medicare Advantage Plans are shown below.

Health Maintenance Organization (HMO) Plans
Health Maintenance Organization (HMO) Plans
Preferred Provider Organization (PPO) Plans
Preferred Provider Organization (PPO) Plans
Private Fee-for-Service (PFFS) Plans
Private Fee-for-Service (PFFS) Plans
Special Needs Plans (SNPs)
Special Needs Plans (SNPs)

Other less common types of Medicare Advantage Plans that may be available include HMO Point of Service (HMOPOS) Plans and a Medicare Medical Savings Account (MSA) Plan

Rules for medicare advantage plan

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

Each Medicare Advantage Plan can charge different

out-of-pocket costs

. They can also have different rules for how you get services, like:

Whether you need a referral to see a specialist
If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care

These rules can change each year.

Costs for Medicare Advantage Plans

What you pay in a Medicare Advantage Plan depends on several factors. In most cases, you’ll need to use health care providers who participate in the plan’s network. Some plans won’t cover services from providers outside the plan’s network and service area.

Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for all Part A and Part B services. Once you reach this limit, you’ll pay nothing for services Part A and Part B cover.

Learn about these factors and how to get cost details.

Drug coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include prescription drug coverage (Part D). You can join a separate Medicare drug plan with certain types of plans that:

Can’t offer drug coverage (like Medicare Medical Savings Account plans)
Choose not to offer drug coverage (like some Private Fee-for-Service plans)

You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:

You’re in a Medicare Advantage HMO or PPO.
You join a separate Medicare drug plan.

How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans

You cannot purchase (and do not require) Medigap while enrolled in a Medicare Advantage Plan. Medigap cannot be used to cover any charges (copayments, deductibles, and premiums) associated with a Medicare Advantage Plan. For information on The relationship between Medicare Supplement Insurance (Medigap) insurance and Medicare Advantage Plans. CHECK HERE

Different offered Plans of Medicare Advantage

Health Maintenance Organization Plans (HMO)

HMOs work together with the same care providers, and hospitals inside the plan’s network (with the exception of emergency situations.) A referral from your primary care doctor may also be required for testing or specialty appointments.

Preferred Provider Organization Plans (PPO)

When you use a PPO, you pay less if you utilize doctors, hospitals, and healthcare providers inside the plan’s network, and you pay more if you go outside the network.

Private Fee-for-Service Plans (PFFS)

PPFS plans are similar to Original Medicare in that you can go to any doctor, healthcare provider, or hospital as long as they accept the payment conditions of the plan. The plan sets how much it will pay out and how much you will have to pay as a co-pay.

Special Needs Plans (SNPs)

SNPs specialize on providing health care to those who are more medically needed, such as those with both Medicare and Medicaid, those in nursing homes, and those with chronic medical issues.

HMO Point-of-Service (HMO-POS)

HMOPOS are HMO plans that enable you to get services outside of your network in exchange for a higher copayment.

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What do Medicare Advantage Plans cover?

Except for hospice care, Medicare Advantage Plans cover all of the services that Original Medicare does. Whether you have Original Medicare or a Medicare Advantage Plan, hospice care is covered. You are covered for emergency and urgent treatment in all Medicare Advantage Plans. Outside of the plan's service region inside the United States, Medicare Advantage Plans provide emergency coverage. Many Medicare Advantage Plans include extra benefits such as dental care, eyeglasses, and fitness programs. The majority of Medicare Advantage Plans offer Medicare prescription drug coverage, and you typically pay a single monthly payment for both the plan's medical and prescription drug coverage.

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