Part C: Medicare Advantage
What is a Medicare Advantage?
Medicare Advantage plans are sometimes referred to as Part C or MA Plans. These plans are offered by private insurance companies approved by Medicare and have to follow rules set by Medicare. These are "bundled" plans - meaning they include Medicare Parts A and B and most offer prescription drug coverage too. Depending on the plan, you may pay more for these benefits than you would in Original Medicare. These plans are an alternative to Original Medicare; therefore, with a Medicare Advantage plan, Medicare is no longer your primary insurer.
To get a Medicare Advantage plan, you must:
Be entitled to Medicare Part A
Be enrolled in Medicare Part B
Live in the plan's service area
MEDICARE ADVANTAGE RULES
Medicare Advantage plans have to follow rules set by Medicare. However, each MA company can charge different out-of-pocket costs. In addition, each company can decide how you get different services, like whether or not you need a referral to see a specialist and whether or not you're allowed to see the physician of your choice.
MEDICARE ADVANTAGE COSTS
The amount you pay in a Medicare Advantage plan varies greatly. Each MA plan can charge different out-of-pocket costs. Usually, you will have a network of providers and a service area you must use to get services at a lower cost. Some plans won't pay anything toward a provider used outside the network or service area.
MA DRUG COVERAGE
Most Medicare Advantage plans include prescription insurance. Some cannot offer drug coverage and some choose not to offer any drug coverage. It is very important to know whether or not your plan includes drug coverage because enrolling in a separate Part D plan could disenroll you from your Medicare Advantage plan.
What are the most common kinds of Medicare Advantage plans?
Health Maintenance Organization
Generally, you must use a network of providers in an HMO plan. The exceptions are: emergency care, out-of-area urgent care and out-of-area dialysis. Seeking medical care outside the plan's network usually comes with higher out-of-pocket costs and sometimes, the plan doesn't pay for any care outside of the plan's network.
Prescription drugs are usually covered with HMO plans, but not always. It is up to the company as to whether or not the plan is going to cover prescription drugs.
In most cases, you will have to select a primary care physician within the plan's network. A provider can leave the plan's network at any time. If this happens, you will have to select a new physician in the plan's network. In addition, you usually need a referral to see a specialist when in an HMO.
Preferred Provider Organization
A Medicare PPO plan has a network of doctors and hospitals. You will pay less if you use a provider within the network and will pay more if you use doctors and hospitals outside the network. Certain doctors are "preferred" which saves you money if you use them. Each plan gives you the flexibility to get medical care from a facility that's not on the plan's list, but it will cost you more out-of-pocket.
Most PPO plans cover prescription drugs, but not all. If you choose a plan that does not offer a drug plan, you're still not able to enroll in a separate drug plan; it's important to enroll in a PPO with drug coverage if you want your prescriptions covered.
You do not need to choose a primary care doctor in a PPO plan and, usually, don't need a referral to see a specialist. However, using a physician or specialist outside the plan's network will still cost you more out-of-pocket.
A Private Fee-for-Service plan is a Medicare Advantage plan offered by private insurance companies. The insurance company decides how much it will pay providers for your medical care and also decides how much you will pay for your care. Some PFFS plans have a network of providers. You can go to any Medicare-approved provider that accepts the plan's payment terms and agrees to see you. Not all providers agree to these terms.
Some PFFS plans include prescription drug coverage, but not all. If your PFFS doesn't include a drug plan, you may enroll in a separate Medicare Part D (Prescription Drug) plan.
You do not need to choose a primary care physician with a PFFS plan and also, do not need a referral to see a specialist. However, each time you see a physician or specialist, the provider can decide whether or not to accept the plan's terms of payment.
Special Needs Plan
A Medicare Advantage SNP limits plan membership to those with specific diseases or conditions or those who qualify for both Medicare and Medi-Cal/Medicaid. Medicare SNPs design their benefits and providers based on the individuals they serve. Usually, you must get your medical care from the SNP's network. The exceptions are: emergency care, out-of-area urgent care and out-of-area dialysis. In most cases, the SNP's network of providers has specialists in the diseases and conditions that affect their members.
All SNPs must provide prescription drug coverage.
In most cases, SNPs require you to have an in-network primary care physician or a healthcare coordinator to assist with your health care. Most SNPs also require a referral to see a specialist.