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Medicare Advantage Plans Explained

So let’s get right to it, you have questions about Medicare Advantage, and we have the answers, so let’s get started. Medicare Advantage (MA) plans are Medicare-approved options run by private insurance companies. These plans may also be called Medicare Part C.  They provide the same health benefits as traditional, Original Medicare, but may also provide some additional benefits, such as vision and dental. They may also include a Medicare prescription plan (Part D).
 
There may be some specific provisions of these plans, such as restrictions on which physicians can be used, that members need to be aware of before they enroll. There may be a different cost structure as well, such as additional premiums and out-of-pocket expenses.
Eligibility
Those who are currently eligible for or enrolled in Medicare Part A and B are eligible to enroll in a Medicare Advantage plan, as long as they live within the plan’s service area. Those with End Stage Renal Disease (ESRD) may not be eligible, though. For those patients, there are some different options available through Medicare. A member of an MA plan must provide required information to the company and follow the specified rules of the plan. You can only be in one MA plan at a time.
Enrollment
Medicare Advantage plans are becoming more popular every year. In terms of enrollment, there are two time periods when you can join a Medicare Advantage plan: when you first become eligible for Medicare and during the annual Open Enrollment Period. Your Initial Enrollment Period (IEP) is for the time period of three months before the month you turn 65 through three months after the month you turn 65 (a total of 7 months).
The Open Enrollment Period (OEP) is the annual period of time when Medicare beneficiaries choose their plan for the following year. This runs from October 15 to December 7. If you chose to enroll in a MA plan, that plan must accept you, as long as they are accepting new members, and you live within their plan coverage area. Additionally, you may be able to join or switch plans outside these time frames under certain circumstances. These are called Special Enrollment Periods (SEP), and include the following reasons:

  • Moving away from the service area of your current plan
  • Your current plan leaves the Medicare system or reduces its service area
  • Losing employer or union coverage
  • Entering or leaving a long-term care facility
  • Qualifying for or losing Extra Help status; this Medicare program helps low-income enrollees with Medicare prescription drug costs

Disenrollment
If you are in a Medicare Advantage plan, and you want to go back to traditional Medicare, you may do so from January 1 through February 14. Medicare coverage will be in effect the first day of the month after you submit your request. You can submit your request to switch back to traditional Medicare by contacting your current MA plan or by calling (800) MEDICARE (633-4227).
There are also some special circumstances, when you may un-enroll from a MA plan outside the above time period. These are called special trial rights, and they allow beneficiaries to leave a MA plan and go back to traditional Medicare within the first 12 months of enrollment. This is allowed if the MA plan is your first enrollment when you turned 65. It is also allowed if you were enrolled in traditional Medicare, then joined an MA plan and dropped Medigap coverage.
Types of Medicare Advantage plans
There are several MA plans available, including the following:
Health Maintenance Organization (HMO)
In general, plan services and benefits are limited to within the plan’s network including physician and hospital services.  The exceptions are emergency care, out-of-area urgent care and out-of-area dialysis care. If you receive care outside this network and without the plan’s approval, you will likely have to pay the full cost of that care.
In most plans, prescription drug coverage is included, but it depends on the plan. If you want a drug plan included in your benefits, make sure to join a plan that offers this. Additionally, most HMO plans require members to choose a Primary Care Provider (PCP). He or she will be the primary provider and manager of your medical care. If a specialist is needed, you will likely need to get a referral from your PCP. Preventive care and services, such as a colorectal screening or routine mammogram, do not usually require a referral.
HMO Point-of-Service Plan (HMO POS)
This plan is basically the same as the HMO plan, but includes some out-of-network services and benefits.  These additional services usually will cost more.
Preferred Provider Organization (PPO)
In a PPO plan, you may use in-network physicians and services, or you may choose to go out of network. If you do choose to receive care outside the plan’s network, you will likely have higher out-of-pocket expenses. In most plans, prescription drug coverage is included, but it depends on the plan. If you want a drug plan included in your benefits, make sure to join a plan that offers this. In PPO plans, you do not have to choose a PCP, nor get referrals to see a specialist.
Special Needs Plan (SNP)
SNPs are specifically designed for beneficiaries who have chronic conditions and specific needs related to those conditions. The services offered include specific expertise related to the member’s conditions, as well as focused and coordinated care management for those conditions. Similar to HMOs, Special Need Plan services and benefits are limited to within the plan’s network. This includes physician and hospital services. The exceptions are emergency care, out-of-area urgent care and out-of-area dialysis care.
All SNPs have a prescription drug plan, but do not usually require you to choose a PCP. In order to enroll in a SNP, you must meet one of the following criteria:

  • Live in a long-term or skilled facility, such as a nursing home, or require nursing care at home
  • Eligible for both Medicare and Medicaid
  • Have specific chronic or disabling conditions, including diabetes, End Stage Renal Disease (ERSD), HIV and AIDS, chronic heart failure or dementia

Private Fee-for-Service (PFFS)
In a PFFS plan, a member may see any provider, including physicians and hospitals, as long as those providers accept the payment terms of that plan. Not all providers accept all plans, so you must verify that prior to seeing the provider.
Some plans may have a network of providers that must accept you as a patient. Out-of-network care is allowed, but you may have more out-of-pocket expenses. These plans may or may not have prescription drug coverage. If they do not, you can purchase Medicare drug coverage (Part D) on your own. You will not be required to choose a PCP or get a referral to see a specialist. The costs of these plans will vary, and you need to make sure you understand those costs and any restrictions or rules related to the plan before you decide to enroll.
Medicare Medical Savings Account (MSA)
This MA plan has a high deductible. However, this plan is connected to your bank account and will deposit money on a regular basis for you to cover your out-of-pocket healthcare expenses.
Network changes
Medicare Advantage plans that have networks can make changes to those networks, including contracted physicians and hospitals, at any time during the year. Medicare does have certain safeguards in place, though, to ensure member’s medical care is not interrupted. Additionally, Medicare requires that all networks have the providers and services available to cover all Part A and Part B Medicare services. If they do not, due to a change in providers, they must offer additional providers until those services can be provided.
When a provider terminates their contract with the MA plan network, the plan members regularly seen by that provider must be provided with a written notice. This notice must be provided 30 days in advance of the contract termination and provide the member alternative providers in the network. It must also outline how the member can choose a different provider.
Choosing the right medical coverage for you is an important decision. In order to determine if a Medicare Advantage plan is the right choice for you, you must review all the options available, as well as the advantages and disadvantages of each plan. Furthermore, each company that offers a MA plan will have different requirements and rules associated with the benefits and coverage. It is very important for a potential member to review all the requirements and provisions of a plan before they enroll. This includes medical care coverage and networks, additional costs and specific benefits. With this information, you will be better able to decide which plan is right for you.