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MEDICARE ADVANTAGE PLANS

[PART C of Medicare]

What is Part C – Medicare Advantage?

A Medicare program that offers health plans through private insurance companies that contract with Medicare. These plans may be available with drug coverage (MAPD) or without prescription drug coverage (MA).

A + B ( + sometimes D ) = Part C

Part C may also include some additional benefits such as:

Dental. Vision, Hearing, Gym Membership, Over-the-counter allowances, Healthy Food/Drink Cards, Podiatry, Chiropractic & Acupuncture, 24/7 Nurse Hotline, PERS (Personal, Emergency Response System), Plus Other Perks!

If the plan includes prescription drug coverage, it is called a “MAPD”
(Medicare Advantage Prescription Drug plan).

If the plan does not include prescription drug coverage it is called a “MA”

Medicare Advantage Plan

All Medicare Advantage and Medicare Advantage Prescription Drug plans are required to cover at a minimum, at least all the same benefits that Original Medicare offers. Clients do NOT lose any Original Medicare benefits when they join an Advantage plan.

How does a person qualify for a MA/MAPD plan?

  • Must be eligible for Medicare
  • Must continue to pay your Part B premium
  • Must pay your MA/MAPD monthly premium, if applicable
  • Cannot have ESRD (End Stage Renal Disease) = cannot be waiting for a transplant

MA/MAPD’s put Original Medicare in hibernation by replacing it and adding additional benefits, generally improving and augmenting Original Medicare with perks.

How does a MA/MAPD plan work?

By definition, Medicare Advantage plans replace the benefit structure of Original Medicare. (It’s supposed to add more coverage and more protection.)

The Client is still a part of Medicare, however, the Client gets all of their Medicare-covered health care from the private carrier’s health plan they choose.

The Client will NOT lose their Medicare when they join a Medicare Advantage plan!  In fact, they MUST have Original Medicare to be eligible for a MA/MAPD.

Always remember that the Client must continue to pay for their Part B premium.

 

! Important: People often misunderstand and/or misuse the word “Supplement.” Know that Medicare Advantage Plans are NOT Medigap Supplement Plans. Medicare Advantage Plans are NOT Medicare Supplement Plans. They are totally different! Please watch Core Medicare’s Video Tutorials to learn more

 

To keep the Client’s costs down, they might have to choose doctors that are in the plan’s network.

When the Client goes to the doctor, they will use the insurance card from the MA/MAPD plan, NOT their Original Medicare Card.

Each plan provider (carrier) can charge different out-of-pocket costs and have different rules for how the Client accesses/utilizes services.

These plans vary throughout the USA. The plans are available by County.

There is NO underwriting for MA/MAPDs.

  • Medicare beneficiaries can join MA or MAPD plans even if you have a pre-existing condition, like End Stage Renal Disease (ESRD) or you’re receiving renal dialysis, You can now be approved for any MA/MAPD plan available in your county.
  • If you receive TRICARE (a type of military health coverage, or CHAMP VA, we recommend that you do not enroll in a MA or MAPD, because it can conflict with your military benefits and cause issues.
  • A person CANNOT be enrolled in a MA/MAPD and a stand-alone PDP at the same time. The only time a medicare beneficiary can have both a MA and a PDP is if the MA is a PFFS without drug coverage.”

PFFS = Private Fee for service

One exception to this is:  PFFS + Stand-Alone PDP ???

Why should I get a Medicare Advantage plan?

(What does the Advantage plan have that Medicare doesn’t?)

  • The copays, deductibles, and coinsurance under a MA/MAPD plan are typically lower (than Original Medicare).
  • Limits your maximum out of pocket
  • Might offer extra benefits like dental and vision
  • MAPDs have prescription drug coverage included in the plan versus having to purchase it separately.

[Quote: “Fully subsidized Medicare still requires that you pay the Plan B premium.”]

What types of Medicare Advantage plans are there?

  • HMO
  • PPO
  • HMO-POS
  • PFFS
  • D-SNP (Dual Special Needs Plan)
  • C-SNP (Chronic Special Needs Plan)

All plans are Network based (except some PFFS plans)

These plans function as MA or MAPD

All about the HMO (Health Maintenance Organization)

  • Beneficiary only has access to IN-NETWORK PROVIDERS.
    • If they go to a NON-NETWORK PROVIDER, neither Medicare nor the HMO will pay for the services unless there is an emergency.
  • Beneficiary is assigned a participating PRIMARY CARE PHYSICIAN (PCP) to monitor the beneficiary’s health care. Sometimes called an “overseer” or a “gatekeeper.”
  • Beneficiary typically must receive a REFERRAL from their PCP to go and see a specialist.
    • This is done to minimize costs
    • Because of this, typically HMO’s have lower copays and lower coinsurance for the beneficiary.

All about the PPO (Preferred Provider Network)

  • Beneficiary has access to in-network and out-of-network providers
    • The beneficiary will usually pay more for services with an out-of-provider, unless it is an emergency.
    • Referrals to specialists are NOT required

All about the HMO-POS (Health Maintenance Organization – Point of Service)

  • This is a hybrid of the HMO and PPO: It is a HMO, but has select out-of-network benefits similar to a PPO
  • You will typically pay a higher cost for the select out-of-network benefits (unless it’s for an emergency / not penalized for an emergency).
  • Referrals are usually required. See the plan’s Summary of Benefits to confirm.

All about the PFFS (Private-Fee-For-Service) – usually for rural areas

  • This is a hybrid of Medigap and Medicare Advantage Plans
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