There are two ways of getting Medicare coverage- Original Medicare and Medicare Advantage plans.
Original Medicare covers Hospital – Part A insurance and Medical known as Part B insurance. But if you wish to get drug coverage you have to join a separate Medicare drug plan, also known as Part D.
This is not the case with the Medicare Advantage coverage. A Medicare Advantage plan is also known as Part C. This plan combines what is covered under Part A and B as an all in one coverage that includes a lot of extra benefits that are not a part of the original Medicare plan. This plan bundle covers vision, hearing, dental, etc. and the usual Part A, Part B and Part C.
What are Medicare Advantage Plans?
There are mostly four types of Medicare advantage plans- Health maintenance organization (HMO) Plans, Preferred Provider Organization (PPO) plans, Private Fee-for-Service (PFFS), Plans and Special Needs Plans (SNPs).
Find a plan that fits your unique needs
Health maintenance organization (HMO)
- Provides health care coverage from doctors, hospitals, nurses etc. available in the plan’s network for certain services.
- It does not cover emergency care, out-of-area urgent care and out-of-area dialysis.
- Provides coverage with set provider networks – This could be a smaller network of providers to choose from.
- Could require less paperwork than other plans.
- Requires referrals from your primary physician to see a specialist.
Preferred Provider Organization (PPO) plans
- Usually a larger network (with some out of network coverage) – Choice of more hospitals, doctors, or specialists.
- Plans typically do not require a referral to see a specialist. (Some specialists still require referrals regardless of the plan you are on)
- Higher premiums.
- Usually have a deductible.
Private Fee-for-Service (PFFS) Plans
- Reimbursement takes place on a fee-for-service basis, at a rate fixed in the plan.
- Can get services outside service area.
- Plans typically do not require a referral to see a specialist. (Some specialists still require referrals regardless of the plan you are on)
Special Needs Plans (SNPs)
- There are 3 types of SNPs- C-SNP (chronic condition SNP), D-SNP (Dual eligible SNP), I-SNP (Institutional SNP).
- C-SNP- For beneficiaries with a chronic, special medical condition.
- D-SNP- For Medicare beneficiaries who are also eligible for Medicaid.
- I-SNP- For beneficiaries who reside in a long-term care facility.
- May charge a premium in addition to Part B premium.
- Provides Medicare prescription drug coverage.
- Might need a referral to see a specialist.
- It does not cover emergency care, or out-of-area dialysis, however, if your SNP is a PPO you can get Medicare services outside your network.
How do Medicare Advantage plans work?
The company offering your Medicare Advantage Plan is paid a monthly premium to be your insurance carrier. Medicare also has a set of rules that the companies must abide by. These rules can change each year. The plan must notify you about any changes before the commencement of the next enrolment year.
Medicare Advantage Plans usually operate with set copay’s rather than the traditional 80/20 split of original Medicare and can set rules you need to follow (like whether you need a referral to see a specialist or if you have to go to doctors, facilities, or suppliers that belong to the plan’s network for non-emergency or non-urgent care). If you join a Medicare Advantage Plan, you’ll have all of the same rights and protections that you would have under Original Medicare.
What do Medicare Advantage plans cover?
Most Medicare Advantage Plans offer coverage, for some things Original Medicare doesn’t cover, like vision, hearing, dental, and fitness programs (like gym memberships or discounts). Almost all Part A and Part B services are covered by Medicare Advantage Plans. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care.
Plans also have a yearly limit on your out-of-pocket costs for all Part A and Part B medical services. Once you reach this limit, you’ll pay nothing for services Part A and Part B costs. Most Medicare Advantage Plans also include Medicare drug coverage (Part D). In certain types of plans that don’t include Medicare drug coverage (like Medical Savings Account Plans and some Private-Fee-for-Service Plans), you can join a separate Medicare drug plan.
Cost coverage – What you pay for a Medicare Advantage Plan.
Health and prescription drug costs that are not covered by insurance or your out-of-pocket costs depend on:
- Premium – Most Medicare Advantage plans have a $0 premium. But, if your plan charges you a premium and you are not covered under Medicare premium reduction, you pay this in addition to the Part A and B premium.
- Deductibles– The amount that you have to pay for your health care and prescription drugs before your insurance begins to pay, determine your deductibles. Your out-of-pocket costs vary if your plan includes a yearly or any additional deductibles.
- PPO, PPR, OR MSA Plan –As different plans abide by different terms and conditions.
- Co-payment or Coinsurance–The plan may charge a co-payment, like $10 or $20 every time you see a doctor. This is the amount you are required to share as a part of the agreement.
- The type of health care service you need and how often you need it.
- The plan’s yearly limit on your Health and prescription drug cost for all your medical services.
- Out-of-network – Medicare Advantage Plan generally gives you a choice to get plan services outside of the plan’s network. But if your out-of-pocket cost exceeds your out-of-network benefit, you pay for the extra amount.
- If you have Medicaid – Medicaid programs (a joint federal and state health initiative) vary from state to state, but if you qualify for both Medicare and Medicaid most of your health care costs are usually covered but there could still be some value in joining a Medicare Advantage Special Needs plan.
To choose a plan, we recommend speaking with a local licensed insurance agent that can help! For immediate assistance, you may call us at 210-908-6565.
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