Medicare Advantage

Key Takeaways:

1. ‌Medicare Advantage goes beyond the original medicare but can still have extra coverage.

2. Medicare Advantage there are many different types and options available but may be based on location and provider.

3. Changes may occur every year so it is advised to review your plan annually.

4. With different enrollment periods, understanding the right one can save you money in the long run.

 

The information below reviews:

• Purpose of Medicare Advantage?

• How they work?

• What is their cost?

• What is covered?

• Pros and Cons of Medicare Advantage?‌
   

The 4 Parts of Medicare 

If you are

• 65 and older

• Under 65 and have certain qualifying disabilities

• Those with diagnosed end-stage renal disease

The 4 categories in the Medicare System are:
 

1. Part A (hospital insurance)  covers inpatient stays and qualifying skilled nursing, hospice, and home health care. If you've worked and paid Medicare taxes for at least ten years or meet other eligibility criteria.

2. Part B (medical insurance) covers outpatient care, office-based doctors' services, and medical supplies. Part B coverage requires that you pay a monthly premium.

3. Part C (Medicare Advantage)  is an alternative to Parts A and B. You purchase Part C coverage through private insurance companies.

4. Part D (prescription drug coverage)  helps to cover the cost of prescription medication. Premiums vary based on the coverage options you choose. If you have Medicare Part C, drug coverage may already be a part of your plan

You can sign up for each individually, the Original types are Part A and Part B. What A & B doesn't cover. Part C a Medicare Advantage can cover what A and B doesn't.
 

What is Part C (Medicare Advantage)?

The Part C or Medicare Advantage is an alternative to Parts A and B as well as supplemental coverage.
 

For Patients, Medicare Advantage can save money while improving coverage. Medicare Advantage covers in/out patient and can include additional benefits like:

• Vision care
• Dental care
• Hearing services
• Fitness programs
   

A multitude of Medicare Advantage means each have their own costs and benefits. There is no reason to not-shop all the options like you would a private plan. You will still have coverage with Original Medicare and all that goes along with it.
 

How Does Medicare Advantage Work?

As a member with a Medicare Advantage plan, your Medicare coverage will send money ever month to your insurer. This is an automation in the system so you can focus on other things and this is how Medicare can keep coverage affordable. If the total amount that Medicare is less than the total cost of your plan it is your responsibility to pay the difference which is the premium. This premium varies dependent upon where you live, your selected plan and the insurer. Once you're a Medicare Advantage member, Medicare will send a fixed amount every month to the company that insures you. This payment is part of how Medicare keeps coverage affordable. It happens automatically within the system, so you don't have to think about it.
 

Details

Medicare sets rules that insurance companies who provide Medicare Advantage plans are required to follow. Each year, Medicare receives bids from insurance companies for coverage and premium costs, the details are thoroughly reviewed to make sure that these companies and their coverages meet all federal guidelines in place. If the insurance companies meet the federal guidelines they are able to set a price and create Medicare Advantage plans.

Some of these requirements can include but are not limited to care from in-network providers and getting referrals from PCP's for specialists.  Getting the care needed may be different if you have had Medicare previously. Typically Medicare allows care from any providers including specialists that accept Medicare. 
 

Coverage Changes

As insurance companies are independent from Medicare they are able to make changes to their plans, rules and benefits on a yearly basis. If this happens you will be notified before the coverage begins for your next year so you can choose a new plan if necessary. It is important that you take these notifications seriously as you need to make sure you will continue to have the coverage you need. During open enrollment you are able to select a new coverage plan to meet your needs. 

What Does Medicare Advantage Cover?

Medicare Advantage covers everything that Original Medicare does, and sometimes more.
 

Hospitals

Hospital, eligible inpatient and nursing home care are that are included in Medicare Part A are also offered in Medicare Advantage. Since Medicare Advantage must give you at minimum the same care as Medicare the plan you choose has to cover in-patient care for a minimum of 90 days.
 

Medical care

Medicare Advantage covers 2 services similar to Medicare Part B. 

1. Necessary Supplies/care that is needed to diagnose/treat medical conditions.
2. Preventative illness care or care to detect early illnesses for effective treatment 
    

The following are covered:

• ‌Doctor's visits

• Ambulance services

• Mental health 

• Medical equipment (wheelchairs, walkers, etc.)
   

‌Please note that there may be a required co-pay dependent on your plan.
 

Prescriptions

Prescription coverage are included in most Medicare Advantage plans.

If your plan doesn't include prescriptions you might be able to get a Part D plan, depending on the type of plan you have. 

• You can join Part D plan with a Private Fee for service plan or medical savings account.

• You cannot join if you have an HMO (health maintenance organization) or PPO (preferred provider organization)
   

Out-of-pocket costs 

Some Medicare Advantage plans require a copayment for prescription medicine, the total amount is dependent on the type of medication. These plans may also include a medication deductible.
 

Other benefits

There are some services not available under traditional Medicare or Part D plans that may be covered under a Medicare Advantage plan, these are listed below:

• Standard Dental Care
• Vision: Eyeglasses and contact lenses
• Hearing: Services, including hearing aids
• Fitness Services
• OTC Medication: Money for a variety of medical items like band-aids and vitamins
• If circumstances are met, food delivery services
   

What Does Medicare Advantage Not Cover?

Medicare Advantage, like traditional Medicare, do not allow for:

• Unnecessary services including but not limited to cosmetic surgeries

• Placement for Long-term facilities

If skilled nursing services are needed for certain medical conditions, Medicare Advantage may cover it if you have been released from the hospital and still have in-patient care days that are unused.

Medicare Advantage plans do not include custodial care which are services that help with normal living activities that include, cooking, eating, showering/bathing or using the bathroom. Another way to think of it is if it isn't a skilled nursing task it is considered custodial care.
 

Pros and Cons of Medicare Advantage

Some of the pros and cons for Medicare advantage are as follows:

Pros:

• Hearing, vision and dental plans may be available unlike standard Medicare. 

• No unexpected increases of expenses

• There are maximums for out-of-pocket costs
   

Cons:
You must follow the guides of how and where you can get treatment
Differing costs from Medicare
You cannot purchase a supplemental plan to help with items like deductibles and co-payments
 

Types of Medicare Advantage Plans

The 6 types of Medicare Advantage Plans
 

HMO's (Health maintenance organizations)

Before choosing a plan it is necessary to check all requirements as Coinsurance HMO plans have become more popular. A Health Maintenance Organization works with an insurer in order to make a standard cost. These plans do make it necessary to see specific in-network providers, with the exclusion of emergencies that are qualified. 
 

PPO's (Preferred provider organizations)

Like an HMO a PPO does have in-network providers however you are provided with a little flexibility where you choose to get treated; this advantage does require a higher payment. Another advantage of a PPO is referrals from your doctor are not required in order to see a specialist.
 

PFFS (Private fee-for-service plans)

A Private fee-for-service plan has contracted providers at a reduced rate. One Difference is an agreement where the doctor or facility must see a patient even if the are new to the facility and the provider is required to see the dr. without a referral and if the member is a new patient. 
 

Special needs

For members with medical conditions like (but not limited to) HIV, end-stage renal disease, dementia and diabetes, a special needs plan is available where in-network providers are the only providers a member can see. These providers are specialists in the area of care needed for the member. These plans also include the necessary medication coverage needed by the patient for their condition.
 

High-deductible health plans

With the possibility of a lower premium you may have higher out-of-pocket costs before the activation of your coverage.
 

MSA (Medical savings account )

This coverage is a supplement to a Medicare Advantage plan. For those with a Medicare Advantage plan that requires a high-deductible this plan takes money from the Medicare Advantage plan and puts it in to a separate account that you use for only certain qualified medical expenses. These help you reach your deductible even though the amount in the account is less than your actual deductible but this money can roll over year to year if kept in good standing. 
 

‌Who is Eligible for Medicare Advantage?

Both must apply for eligibility:

• You must be enrolled in Medicare Part A and Part B.

• You must reside 6+ or more a year in the plans service area. (You can request more information on this from your service provider.)

 

I live in more than one location, what does that mean for my coverage?

Many plans are available regionally vs nationwide. As a member who lives in more than one area it is necessary to make sure that your plan allows you to see providers in both locations or that out-of-network providers are covered.
 

Have more than just one coverage plan?

It is necessary to check if you can join a Medicare Advantage plan because your coverage might change. You can speak with the person of is in charge of your insurance.
 

How Much Do Medicare Advantage Plans Cost?
 

Like other private health insurance forms, Medicare Advantage plans charge a monthly premium and require out-of-pocket payment when you receive care.
 

Monthly premiums

A premium can be paid monthly or annually which keeps your plan active. Currently (which may change at any time) $21 is the monthly premium for Medicare Advantage. Although not free some Medicare Advantage plans can have a $0 premium however your Premium for Part B is still your responsibility. Keep in mind that there are some Medicare Advantage plans that help part or all of the premium for Medicare Part B.
 

Deductibles

The amount you pay for treatment before your coverage begins is your portion of your deductible. As an example, let's say your plan has a $1000 deductible you are responsible for paying that same amount before any covered treatments or services. Some plans do cover annual check-ups. Regular insurance can have deductibles up to $10,000 but some Medicare Advantage plans have 0 deductibles. In some circumstances there may be 1 or 2 deductibles you must meet for some services like prescriptions, outpatient care and hospital services. It is suggested to carefully review your plan. 
 

Copayments/Coinsurance

Copayments and coinsurance are payments that you make toward the cost of care. They're part of the cost-sharing system that underlies most private health insurance — you pay a portion of the cost of care, and the insurer covers the rest.

These are the portion of payments you make for cost of care. The costs vary dependent on the following:

• Copayments: Fixed amounts paid for some services

• Coinsurance: Percentage of total cost for care

 

Depending on your plan, these payments may not go toward your deductible.

 

Out-of-pocket maximum

Out-of-pocket are maxed out in Medicare Advantage plans. The amount spent is kept count of over a year and will include paid deductibles, and both copays and coinsurance. When the total is met, the insurer will cover the cost of services through the end of the plan year.
 

Other factors that affect cost

Cost with Medicare Advantage depends on needed services and the frequency needed. Contribution costs can include:

• If your plan requires in-network providers

• Max yearly out-of-pocket costs

• Insurance (health) paid by Medicaid or other state assistance

• Plan Type

• Add-on benefits
   

How Do You Enroll in Medicare Advantage?

You can join, change or leave a Medicare Advantage plan during 4 times per year. 
 

1. Initial Enrollment

Medicare, starts 3 months before you turn 65. i.e. your birthday is in August your initial enrollment starts on May 1st. It lasts for 7 months i.e. birthday is on May coverage ends on the last day of November. If you're under 65, have a disability that makes you eligible for Medicare your can enroll 21 months after you start receiving benefits (Social Security of Railroad Retirement Board Benefits). 
 

2. General Enrollment

Generall enrollment is from January 1 - March 31. if you sign up for Part B and already have Part A during this time period you care able to enroll in a Medicare Advantage Plan between April 1 and June 30 of that year.
 

3. Open Enrollment

Open Enrollment is from October 15 and December 7 every year. If your new plan gets your app by the last day of open enrollment. During this enrollment period anyone who has Medicare can drop, switch or join a Medicare Advantage plan.
 

4. Special Enrollment

Special Enrollment can be joined of changed under certain conditions like:

• Change of Address
• Loss of current coverage (Cobra/Drug Coverage)
• The plan is dropping it's contract with Medicare
• Change in Medical Condition affects eligibility for Special Needs Plan

Have questions about your eligibility for a Special Enrollment Period? Contact MedicareOptions.PRO today. 

Finding a Medicare Advantage Plan and Provider

Private insurance companies offer Medicare Advantage plans.  What is offered varies on the company selected and the location you reside in. It is important to review each plan so you can make sure of what is covered, the facilities/providers are within the network. Our licensed agents can help you determine which plan from different companies might work best for you. With MediacreOptions.PRO can help you find that fits your situation, specific needs and personal preferences.