What is Medicare Advantage (Part C)?
Medicare Part C, also known as Medicare Advantage (MA), is an alternative way to get Original Medicare (Part A and Part B). It is also a cost-effective and potentially money saving option because it has out-of-pocket limits on costs associated with your covered services. Once you reach the limit, you pay nothing for the rest of the year.
Unlike Original Medicare, Medicare Part C is offered by private insurance companies. Federal government rules and regulations, however, regulate these private companies.
To enroll in a Medicare Advantage plan, one must be eligible for Original Medicare, and may enroll during one of these periods: Initial Enrollment Period (IEP), Annual Election Period (AEP), or during a Special Enrollment Period (SEP).
What Does Medicare Advantage Cover?
Medicare Part C offers coverage for the same Medicare Part A (Inpatient/hospital services) and Part B (outpatient/medical services) services. It also may provide coverage for certain items and services NOT covered by Original Medicare Part A and B depending on available plans in your area. Additional items and services that Medicare Part C may cover include:
● Prescription drug coverage (Medicare Part D)
● Routine vision care, including glasses and contacts
● Routine dental care, including x-rays, exams, and even dentures
● Hearing care, including testing and hearing aids
● Wellness programs and gym memberships
● Medical Transportation
● Non-medical services including meal delivery, home air cleaners, and home modifications.
What Are The Various Types Of Medicare Part C Plans?
Medicare Part C plans are of 5 different types. They are:
● Health Maintenance Organization (HMO) plans
● Preferred Provider Organization (PPO) plans
● Private Fee-for-Service (PFFS) plans
● Special Needs Plans (SNPs)
● Medicare savings account (MSA) plans
Health Maintenance Organizations (HMOs) Plans
With HMO plans, you enjoy Medicare benefits only when you get your care and services from providers within the plan’s network.
Some HMOs, however, offer a point of service (POS) option which allows you to get certain out-of-network services. These out-of-network services often cost more than if you had gotten them from a network provider and may require plan approval before obtaining services.
Many HMO plans will include prescription drug coverage. Note that you cannot subscribe to a separate Medicare Part D plan.
With an HMO plan, there are certain services you may get from any other provider, even if they do not participate in your network. They are:
● Emergency care
● Out-of-area urgent care
● Out-of-area dialysis
Preferred Provider Organizations (PPOs) Plans
With a PPO plan, you can use any doctor, healthcare provider, or hospital of your choice, as long as they accept Medicare and are willing to bill the plan. You generally pay less if the healthcare provider or facility is within your plan's network and more if they are not.
Most PPO plans also offer prescription drug coverage. Note, Just like with HMO’s, you cannot join a separate Medicare Part D (drug coverage) plan if you have a PPO plan. So if you take prescription drugs, it is important to make sure that the plan you choose has optimal coverage for your needs.
Private For-for-Service (PFFS) Plans
PFFS plans draw their payment terms for healthcare providers, facilities, and clients when they get care. You can see any health-care provider within the plan's network or any out-of-network Medicare provider who accepts to treat you on the plan’s payment terms. Usually, services from providers outside the plan’s network cost higher and, in some cases, may not be covered by your plan.
Special Needs Plans (SNP) Plans
Special Needs Plans can be HMOs or PPOs. Special Needs Plans are designed for people who meet certain eligibility requirements. The people usually meet specific health criteria, such as having certain chronic and disabling health conditions or qualifying for Medicare and Medicaid. These criteria form the two most common types of SNPs. They are Chronic Special Needs Plans (C-SNPs) and Dual Eligible Special Needs Plans (D-SNPs).
Condition Special Needs Plans (C-SNPs)
This type of plan is for those with chronic health conditions. At the time of enrollment, your physician will be asked to fill out a chronic condition verification form.
This type of SNP usually has a network including hospitals, pharmacies, physicians, specialists, and other health professionals who specialize in treating chronic diseases or conditions that affect their members. Examples of such chronic diseases include heart disease, pulmonary disease and diabetes.
Dual Eligible Special Needs Plans (D-SNPs)
People eligible for both Medicare and Medicaid are known as the dual-eligible population. D-SNPs are available to this group of people and are characterized by very low or no costs in terms of premiums, deductibles, copays, and other out-of-pocket costs.
Some D-SNPS, like other managed care plans, may provide supplemental coverage for dental care, vision care, meal delivery, and transportation to and from physician offices.
Some SNPs cover services from providers out of network (PPO’s), while some do not (HMO’s). All SNPs must provide drug coverage. D-SNP plans are best known for their value added services or “Extra Benefits” that they may provide to people with limited financial resources.
Medical Savings Account (MSAs) Plans
MSA plans are not so common. Clients with MSA plans have a high deductible and health savings accounts where they deposit money monthly. MSA plans do not have drug prescription coverage
What are Medicare Advantage Costs?
The premium you'll pay when enrolled in a Medicare Advantage Plan depends on the plan. Some plans do not charge a monthly premium, while some do. If your plan does, you will pay the stated amount in addition to the Part B premium and the Part A premium (if you are not enrolled in premium-free Part A).
Deductibles, Coinsurance & Copayments
The amount you pay for Part C deductibles, coinsurance, and copayments varies by plan. They also depend on:
● The healthcare services you need and how frequently you need them
● Whether you need extra benefits and if your plan charges for it
● Whether or not you go out-of-network
● The plan you're on (HMO, PPO, PFFS, SNP, or MSA)
● Whether you have Medicaid or get help from your state
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