| Medicare Part C - Medicare Advantage Plans (as of 1/31/07) |
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Medicare Advantage Plans are health plan options that are approved by Medicare and run by private companies. They are part of the Medicare Program, and sometimes called “Part C.” In many cases, the premiums or the costs of services (co-pays) can be lower in a Medicare Advantage Plan than they are in original Medicare or original Medicare with a Medigap policy.
- Medicare Advantage Plans (MAP) provide all of your original Medicare Part A (hospital) and Part B (medical services) coverage and must cover medically-necessary services.
- Note, DO NOT dis-enroll from Part B!
- In many cases, your costs for services can be lower than if you stay in original Medicare.
- MAP plans generally offer extra benefits, and many include Part D drug coverage.
- MAP plans often have networks, which means you may have to see doctors who belong to the plan or go to certain hospitals to get covered services.
- Some of these plans coordinate your care, using networks and referrals, more than others.
- Some of these plans require referrals to see specialists.
- MAP plans also include options that provide specialized care for people who need a lot of health care services.
- Even if you are out of the service area of the plan, you are still covered for emergency or urgently needed care.
Medicare Advantage Plans include–
- Medicare Preferred Provider Organization (PPO) Plans,
- Medicare Health Maintenance Organization (HMO) Plans,
- Medicare Private Fee-for-Service (PFFS) Plans,
- Medicare Special Needs Plans, and
- Medicare Medical Savings Account (MSA) Plans.
Who can join?
You can generally join if
- you live in the service area of the plan you want to join. In Health Maintenance Organization (HMO) Plans, the service area is also usually where you get services from the plan. Contact the plan.
- you have BOTH Medicare Part A and Part B.
- you don’t have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant, some exceptions).
If you join...
- you are still in the Medicare Program.
- you still have Medicare rights and protections.
- you still get complete Medicare Part A and Part B coverage.
- you usually get prescription drug coverage (Part D) through the plan. In most Medicare Advantage Plans, if your plan offers Medicare prescription drug coverage and you want drug coverage, you must get it from your plan. In these cases, if you join a stand-alone Medicare Prescription Drug Plan, you will be dis-enrolled from your Medicare Advantage Plan.
- If you have a Medicare Private Fee-for-Service Plan that doesn’t offer Medicare prescription drug coverage, or if you have a Medicare Medical Savings Account Plan, you can also join a stand-alone Medicare Prescription Drug Plan.
- you may be able to get extra benefits offered by the plan, such as coverage for vision, hearing, dental, and/or health and wellness programs.
- you still pay the Part B premium. You also pay the Medicare Advantage Plan’s premium that includes coverage for Part A and Part B benefits, prescription drug coverage (Part D if offered), and any other extra benefits (if offered).
- you usually will have to pay some other costs (such as co-payments or coinsurance) for the services you get. Out-of-pocket costs in these plans are generally lower than in Original Medicare, but vary by the services you use.
- you don’t need to buy a Medigap (Medicare Supplement Insurance) policy.
- in some cases, your costs could be higher than the Original Medicare Plan, like if you see a doctor that doesn’t belong to the plan.
Compare how three types of Medicare Advantage Plans work. Since each plan can vary, it’s important for you to read the plans' materials carefully.
| Preferred Provider Organization (PPO) | Health Maintenance Organization (HMO) | Private Fee-for-Service (PFFS) | |
| Are prescription drugs covered? | In most cases. If you want prescription drug coverage, you must get it from the plan. The cost for coverage will be included in the premium. | In most cases. If you want prescription drug coverage, you must get it from the plan. The cost for coverage will be included in the premium. | Sometimes. If your plan doesn’t offer drug coverage, you can join a Prescription Drug Plan in your area. |
| Do I need to choose a primary care doctor? | No | Yes. In most cases you must see a primary care doctor to get a referral before you see any other health care provider. | No |
| Can I get my health care from any doctor or hospital? | Yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost. | No. You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency or urgent care). If the plan has a Point-of-Service (POS) option, you can go out-of-network, but you will pay more than for services in-network. | In most cases. You can go to any Medicare approved doctor or hospital that accepts the plan’s payment terms for covered services. |
| Do I have to see a primary care doctor to get a referral to see a specialist? | No | In most cases. Women don’t need a referral for a yearly screening mammogram or an in-network pap test and pelvic exam (at least every other year). | No |
| What else do I need to know about this type of plan? | Contact the plan before you get a service to find
out if the service is covered and how much it costs. Follow the plan’s rules when needed. Regional PPOs (which serve an entire state or multi-state area) limit your out-of-pocket costs but may have a higher yearly deductible and/or premium than other PPOs. Extra benefits are often offered for an extra premium. |
If your doctor leaves, your plan will notify you.
You can choose another plan doctor. If you get health care outside the plan’s network, you may have to pay the full cost of the services yourself. Follow the plan’s rules, like getting prior authorization when needed. Extra benefits are often offered for an extra premium. |
PFFS plans are different from the Original Medicare Plan. PFFS plans are offered by private companies. The private company, rather than Medicare, decides how much it will pay and what you pay for the services you get. Extra benefits are often offered for an extra premium. |
Note: If you have limited income and resources, you may qualify for help paying your health care costs.
The following types of health plans are also Medicare Advantage Plans. They are available in some areas to people who meet certain conditions.
Medicare Special Needs Plans
Medicare Special Needs Plans are specially designed for people with certain chronic diseases and other specialized health needs. These plans must provide all Medicare Part A and Part B health care and services. They also must provide Medicare prescription drug coverage (Part D). Generally, they offer extra benefits and have lower co-payments than the Original Medicare Plan.
Medicare Special Needs Plans are designed to meet the needs of people:
- who live in certain institutions (like a nursing home),
- are eligible for both Medicare and Medicaid, or
- have one or more specific chronic or disabling conditions.
The plan may limit membership to people in one of these groups, but may enroll other people as well.
A Medicare Special Needs Plan may help manage and coordinate the many services and providers their members use to help them stay healthy, follow their doctor’s orders related to diet and prescription drugs, and help coordinate coverage between Medicare and Medicaid. They may also identify a care coordinator to develop personal care plans to coordinate all health care provider efforts to meet the patient’s needs. For example, a Medicare Special Needs Plan for people with diabetes might use a care coordinator to help members monitor blood sugar, follow their diet, get proper exercise, get needed such as eye and foot exams, and get the right medicines to prevent complications.
A Medicare Special Needs Plan for people with both Medicare and Medicaid might help members access community resources and coordinate many of their Medicare and Medicaid services.
Use the link above to visit Medicare on the web to get help learning about and comparing Medicare Special Needs Plans in your area. Select “Compare Health Plans and Medigap Policies in Your Area.” Or, call 1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048.
Medicare Medical Savings Account Plans (MSAs)
Medicare Medical Savings Account Plans (MSAs) may be offered. These Medicare plans are similar to Health Savings Account plans available outside of Medicare, and they have two parts. The first part is a Medicare Advantage Health Plan with a high deductible. This health plan won’t begin to pay covered costs until you have met the annual deductible, which varies by plan. The second part is a Medical Savings Account into which Medicare deposits money that you may use to pay health care costs.
To see if any MSA plans are available in your area, use the link above. Select “Find & Compare Medicare Plans.” Or, call 1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048.
Medicare Advantage Plans with Prescription with Drug Coverage
Most people with a Medicare Advantage Plan get prescription drug coverage through their plans. If you join a Medicare Advantage Plan and it offers this coverage, you must take the drug coverage your plan offers. Some Medicare Advantage Plans don’t include prescription drug coverage. Other options for getting drug coverage include joining another Medicare Advantage Plan that offers prescription drug coverage, or returning to the Original Medicare Plan and joining a stand-alone Medicare Prescription Drug Plan.
Note: If you belong to a Medicare Advantage HMO or PPO, you can only get Medicare prescription drug coverage from your plan (if offered). If you join a stand-alone Medicare Prescription Drug Plan, you will be automatically dis-enrolled from your Medicare HMO or PPO and returned to the Original Medicare Plan.
Your out-of-pocket costs depend on:
- whether the plan charges a monthly premium in addition to your Part B premium. These plans charge one premium for Part A and Part B benefits, Part D prescription drug coverage (if offered), and extra benefits (if offered).
- whether the plan pays all or part of the monthly Part B premium.
- whether the plan has a yearly deductible.
- how much you pay for each visit or service.
- the type of health care services you need and how often you get them.
- whether you follow the plan’s rules.
- the types of extra benefits you need, whether the plan covers extra benefits, and what it charges for them.
Extra benefits offered may help lower your overall out-of-pocket costs. To learn more about your costs in specific Medicare Advantage Plans, use the link above to visit Medicare on the web, or call 1.800.MEDICARE (1.800.633.4227).
Saving on Your Medicare Part B Premium
A few Medicare Advantage Plans may pay all or part of your Part B premium for you. You would still get all Part A and Part B-covered services. You can also call your State Department of Human Services to see if you can get help paying your Part B premium costs.
Saving on Your Prescription Drug Coverage Premium
Your Medicare Advantage Plan’s premium may include the premium for Part B and for Part D (Medicare prescription drug coverage). Some Medicare Advantage Plans may pay all or part of the premium that pays for your prescription drug coverage. Read the plan materials carefully to see if the plan does this. Plans decide each year if they will reduce part or all of your prescription drug coverage premium. If you have limited income and resources, you may also be able to get extra help paying for your prescription drug costs.
How Your Bills Get Paid If You Have Other Health Insurance
Sometimes your other insurance pays your health care bills first, and your Medicare Advantage Plan pays second. Other insurance that may pay first includes:
- employer or union group health plan coverage (when coverage is based on your or a family member’s current employment),
- no-fault insurance (including automobile insurance),
- liability insurance (including automobile insurance),
- black lung benefits, and
- workers’ compensation.
If you have other insurance, tell your doctor, hospital, and pharmacy so your bills get paid correctly. If you have questions about who pays first, or you need to update your other health insurance information, call the Coordination of Benefits Contractor at 1.800.999.1118. TTY users should call 1.800.318.8782. For more information about who pays first, use the link above to visit Medicare on the web.
Other Options to Consider
As you’ve read in this section, Medicare Advantage Plans are a way to get combined Medicare Part A and Part B benefits, and in most cases, prescription drug coverage (Part D). They may also provide more coordinated health care to help keep you healthy and lower your costs. Some plans (like HMOs) might use networks, where you may only be able to see certain doctors or go to certain hospitals.
Your Medicare decisions are important because they affect things like how much you pay and what is covered. Before making any decisions, learn as much as you can about the types of plans and coverage available to you. Here are other options you may want to consider:
- Original Medicare Plan allows you to use any doctor or hospital that accepts Medicare.
- Medicare prescription drug coverage can be added to some Medicare Advantage Plans.
- other Medicare plans, Government, and private insurance may be available to you.
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Source: “Medicare & You 2007”.
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