Medicare Advantage Plans

Printer Friendly Version

What are Medicare Advantage Plans? 

Congress created Medicare Advantage Plans (formerly known as Medicare + Choice) program to provide you with more choices and sometimes, extra benefits, by letting private companies offer you your Medicare benefits. Your choices may include:

• Medicare Health Maintenance Plans (HMO)

• Medicare Preferred Provider Organization Plans (PPO)

• Medicare Private Fee-for-Services Plans

• Medicare Special Needs Plans

Medicare pays a set amount of money for your care every month to these private health plans. In turn, the Medicare Advantage Plan manages the Medicare coverage for its members. If Medicare Health Maintenance Organization, Preferred Provider Organization or Medicare Private Fee-for-Service Plans are available in your area, you can join one and get your Medicare-covered benefits through the plan. The plan may have special rules that you need to follow. You may have to pay a monthly premium for the extra benefits.

If you join a Medicare HMO, PPO or Medicare Private Fee-for-Service Plan?

• You are still in the Medicare Program.

• You still have Medicare rights and protections

• You may be able to get prescriptions through the plan. If you are in most Medicare Advantage Plans , you must get your Medicare prescription drug coverage from the plans if it's offered. If you have a Medicare Private Fee-for-Service Plan that doesn't cover prescription drug coverage, of if you have a Medicare Cost Plan, you can join a Medicare Prescription Drug Plan.

• You may be able to get extra benefits, such as coverage for vision, hearing, dental and/or health and wellness programs. However, you may have to see doctors that belong to the plan to get these services.

• What you pay out-of-pocket in the addition to the Part B premium depends on the plan's monthly premium amount. Medicare Advantage plans and other Medicare Health plans will have one premium that includes coverage for Part A and Part B benefits, prescription drug coverage (if offered), and any extra benefits (if offered).

• You will have to pay other costs (such as copayments and coinsurance) for services that you get. Generally, your out-of-pocket costs in these plans are lower than the Original Medicare Plan.

Remember, you must have Medicare Part A and Part B to join a Medicare Advantage Plan. If you are already in a Medicare Advantage Plan and have only Part B, you may stay in your plan.

Why do some people join Medicare Advantage Plans? You may be able to get extra benefits like coverage for prescriptions, and more preventative and wellness services. You may get better-coordinated care, and have access to disease management programs. Less paperwork is usually involved compared to the fee-for-service Medicare.  You should contact your local plan administrator to review the benefits and rules for their services.

How does a Medicare Health Maintenance Organization Plan (HMO) work? These are the general rules for how Medicare Health Maintenance Organization HMO's work. For some of these rules, plans may differ slightly, so it is important to call the administrator of your plan.

• In most Medicare HMO's, there are doctors and hospitals that join the plan (called the plan's "network"). You are likely to get most of your care and services from the plan's network. Call the plan administrator to see which doctors and hospitals are in the plan's network.

• If you join a plan, you will be asked to choose a primary care doctor. Your primary doctor is the doctor you see first for most health problems. In many HMOs, you must see your primary doctor before you can see any other health care provider.

• If you want to keep seeing your current doctor, call and ask if he or she is in the Medicare HMO and can continue to see if you join the plan. If not you may want to ask your doctor for a recommendation or choose a different plan.

• If you want to change your primary care doctor, you can ask your plan administrator for the names of the other plan doctors in your area.

• Doctors can join or leave a Medicare HMOs at any time. If your primary care doctor should leave your plan, you will be notified in advance and given a chance to pick a new doctor.

• If you get health care outside the service area of the plan, you may pay for services for yourself. In some cases, neither the Medicare HMO nor the Original Medicare Plan will pay for these services.

• The service area is where the plan accepts members and where plan services are provided. You are covered if you need emergency or urgently needed care and you aren't in you HMO's service area.

• You may need a referral to see a specialist (like a cardiologist). A referral is an OK from your primary care doctor for you to see a specialist or get certain services.

• There are special rules for certain services. If you are a woman, you can go once a year, without a referral for screening mammogram. You can go every year to a specialist in the network for Medicare-covered routine and preventative women's services/ If the type of specialist you need isn't available, the plan will arrange for care outside the network.

• Some Medicare HMOs offer a Point-of-Service option. This allows you to go to other doctors and hospitals who are not a part of the plan ("out-of-network"), but you may pay more.

• If your Medicare HMO includes prescription drug coverage, you will pay a copayment or coinsurance for each covered prescription (unless you have Medicare and Medicaid, and are in an institution like a nursing home).

How does a Medicare Preferred Provider Organization Plan work? Medicare PPOs use many of the same rules as Medicare HMOs listed above.

However, generally in a PPO you can use any doctor or provider that accepts Medicare. You don't need a referral to a specialist or any provider out-of-network. If you go to doctors, hospitals, or other providers who aren't part of the plan ("out-of-network" or "non-preferred"), you will usually pay more. You may want to contact the plan before you get services to find out how much you will have to pay and to determine if the service you want is covered.

Generally, you will get more benefits for lower cost than the Original Medicare Plan. Every PPO plan must pay for all covered services you get out-of network, but every plan is different in what you must pay. Contact your regional PPOs to find out more. 

For more information click on Medicare & You 2008

How does a Medicare Private Fee-for-Service Plan work?

• The Medicare Private Fee-for-Service Plan pays the doctor or hospital for the care you get.  You may have to pay a premium and other costs (like a co-payment) that are different from the Original Medicare Plan.

• You can go to any doctor or hospital that is willing to give you care and accepts the terms of your plan's payment.  You should check how much your out-of-pocket costs will be before joining a Medicare Private Fee-for-Service Plan.

• The private company provides health care coverage to people with Medicare who join this plan.  Before you get care, tell the doctor or hospital that you have a Medicare Private Fee-for-Service Plan.  If the doctor or hospital agrees to treat you, you must pay a fee (like a co-payment) for the services you get.  The private company will pay the rest of the fee.

• The private company may have a "pre-notification" requirement. For example, it may require that you tell the plan of any planned inpatient hospital stays.

• If the plan lets doctors, hospitals, and other providers bill you more than the plan pays for services, you may pay more. If this is allowed, there may be limits to what the can charge, and how much you must pay.

• At the end of each year, the companies offering Medicare Private Fee-for-Service Plans can decide to join, stay with or leave Medicare.

What is a Medicare Special Needs Plan? In 2005, Medicare Health Plans started to offer "Special Needs" Plans. These plans may limit all or most of their membership to people

• in certain long-term care facilities (like a nursing home),

• eligible for both Medicare and Medicaid, or

• with certain chronic or disabling conditions.

Special Needs Plans are available in limited areas. The Special Needs Plans must be designed to provide Medicare health care and services to people who can benefit the most for things like special expertise of the plan's providers, and focused care management. Special Needs Plans also msut provide Medicare prescription drug coverage. In most of these plans, generally there are extra benefits and lower copayments that the Original Medicare Plan. 

For more information click on Medicare & You 2008

Your cost in a Medicare Advantage Plan:

What you pay out-of-pocket depends on:

• Whether the plan charges a monthly premium in addition to your monthly Part B premium. ($96.40 in 2008)

• How much you pay for each visit or service (like a co-payment)

• The type of health care you need and how often you need it

• The types of health benefits you need, and whether the plan covers them

• Whether you follow plan rules. If you do not, you may have to pay the full cost for your care.

n 2006, regional PPOs will be available in most areas of the country to give choices for Medicare health care coverage. Also, local PPOs are now in most areas of the country. Unlike local PPOs, which serve individual counties, regional PPOs will serve an entire region, which may be a single state or multi-state area. The will help bring more plan options to people with Medicare. Just like local PPOs, regional PPO members also will be able to get their Medicare prescription drug coverage for the PPO plan. In a region PPO, members have an added protection for Medicare Part A and Part B benefits. There will be a annual limit on their out-of-pocket costs. This limit will vary depending on the plan.

How will you pay out-of-pocket costs?  It's a fact that even the best health care insurance plans have out-of-pocket expenses. There is a plan designed to supplement your current health insurance plan. It is designed to fill some of the co-pays, deductibles or coverage gaps you would be responsible for should you need care. It gives you benefits available for:

      -  Daily hospital Confinement
      -  Ambulance trips
      -  Durable medical equipment
      -  Skilled Nursing Care
      -  Lump Sum Hospital Confinement
      -  Accidental Death and Dismemberment

      -  Issue ages: 64.5 - 85 years old
      -  Freedom to choose a daily benefit amount between $100 and $600 per day/hospital visit
      -  Choose a 10-day or 21-day benefit period

Coverage to help with expenses such as:
      -  Inpatient/outpatient hospital services
      -  Doctor fees and visits
      -  Emergency room services and supplies
      -  Home Health Care
      -  Medical equipment
      -  Laboratory tests
      -  Ambulance services

For more information about a supplemental insurance for all of those who have 

Medicare Advantage plans, please call 1-888-450-4870.

Top

Senior Care Concepts, 2008