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WHAT IS MEDICARE ADVANTAGE PLAN
Medicare Advantage Plan also to referred to as Medicare Part C is a type of Health Insurance plan offered by private insurance companies that contracts with Medicare to provide all Original Medicare benefits (Part A and Part B benefits) and additional benefits like Prescription drug coverage (Part D), hearing, vision, and dental coverage, as well as gym membership which are not covered for by the Original Medicare.
Medicare advantage plans are an alternative to traditional Medicare, providing beneficiaries (mostly senior citizens and disable adults who qualify) with additional options like Medicare Prescription Drug Part D.
Medicare Advantage plans cover all Medicare services, with extra coverage provided by some plans to include hearing, vision, and dental coverage. Plans can also cover more extra benefits than they have in the past, including services like transportation to doctor visits, over-the-counter drugs, adult day-care services, and other related services that promote beneficiary health and wellness.
If you are in a Medicare Advantage plan, original Medicare still covers hospice care cost, some new Medicare Benefits, and some costs for clinical research studies. In all types of Medicare Advantage Plans, beneficiaries get coverage for emergency and urgently needed care.
HOW DO MEDICARE ADVANTAGE PLANS WORK?
In a Medicare advantage plan, beneficiaries pay a monthly premium to a Private Health Insurer approved by Medicare and in turn, receive benefits for Part A (inpatient hospital) and Part B (outpatient) services.
This is in contrast to the Original Medicare in which a Beneficiary pays a monthly premium to the federal government and receives coverage for inpatient and outpatient services, while subscribing to other Medicare benefits (like prescription drug coverage) separately.
Medicare pays a fixed amount every month to Private Health Insurance companies for beneficiaries’ care and these companies are bounded by rules set by Medicare. Each Medicare advantage plan can charge different out-of-pocket costs. They can also set different rules, regulating how beneficiaries get their service, such as:
- whether a beneficiary needs a referral to see a specialist;
- If a doctor’s visit, visit a facility or drug supplier belonging to the plan in non-emergency situations is necessary.
Out-of-pockets costs in a Medicare Advantage plan depend on:
- If the plan charges a monthly premium cos some plans have no premium
- If the plan pays monthly Medicare Part B premium for its beneficiaries. Some plans pay part or all of its beneficiaries Part B premium.
- If the plan has a yearly deductible or any additional deductible
- The type of health care service required by a beneficiary and how often it can be accessed.
- How much beneficiaries get to pay for each visit or service (that is, in terms of coinsurance and copayments)
- If beneficiaries follow the plans rules like using a network provider
- Whether a beneficiary requires extra benefits and if the plan charges for it
- The plan’s yearly limit on out-of-pocket costs for all medical services
- If a beneficiary has Mediciaid or he/she gets help from the government.
WHAT DO MEDICARE ADVANTAGE PLANS COVER?
Medicare Advantage plans cover all Medicare services and provides extra coverage for vison, hearing and dental coverage. Most plans also offer extra coverage for services wellness programs, gym membership, transportation to doctor visits, over-the-counter drugs, adult day care services and other health-related services aimed at promoting the health and wellness of beneficiaries.
Though not all plans offer all Medicare Advantage benefits, some plans can tailor their benefit packages to offer extra benefits to certain Chronically ill enrollees. A beneficiary can, however, request to see, in advance, if the plan covers a particular item or service.
Sometimes this has to be done for a service to be covered by your plan. If the plan, however, denies a beneficiary coverage, it must be communicated in writing.
MEDICARE ADVANTAGE HEALTH PLANS
Medicare Part C coverage details often varies depending on the Private health insurance company, so it is pertinent for beneficiaries to compare Medicare Advantage plan options that suits their location and health requirements.
The most common types of Medicare Advantage plan available include:
- Health Maintenance Organisations (HMO) Plans
- Preferred Provider Organisation (PPO) Plans
- Point of Service (POS) Plans
- Special Needs Plan (SNP)
- Private Fee for Service (PFFS) Plans
- Medical Savings Account (MSA) Plan
- The Health Maintenance Organization (HMO) Plans: this plan uses a network primary care provider to help coordinate care. HMO plans mostly only pay for providers in the plan’s network except for emergency care, out-of-area urgent care and out-of-area dialysis. HMOs usually have strict guidelines, which means hospital visits and drug prescription are subject to the plan approval. Beneficiaries who decide to use health care providers outside of the plans network may need to pay the full cost out-of-pocket (with exceptions to emergency or urgent care).
- Point of Service Plans (POS): Point of service plans have the benefits of an HMO, but with more flexible provider choice. In this type of plan, costs are generally lower for using in-network.
- Preferred Provider Organization (PPO) Plan: This plan is offered by a private insurance company and it covers providers both in and out of network. The PPO Plan offer a network of Doctors and hospitals for beneficiaries to choose from. Under this plan, a portion of the cost for using an out-of-network provider is paid for by the plan’s providers. You pay less if you use doctors, hospitals, and other health care providers that belong to the plans network but pay more if they are outside the plan’s network.
- Special Needs Plans (SNPs): Special needs plans have benefits that cover special health care or financial needs. Under this plan, membership is limited to those who have certain chronic conditions, are institutionalized, or qualify for both Medicare and dual Medicaid (also known as dual eligible). Medicare SNPs tailor their benefits, provider choices, drug formularies to best meet the specific needs of groups. This plan is quite distinct from the other plans as it pays particular attention to people with specific health care needs.
- Private Fee-for-Service (PFFS) Plans: PFFS plans may or may not have a provider network, but usually cover any provider who accepts Medicare. It allows visits to any Medicare approved doctor or hospital as long as the plans terms and conditions of payment are accepted by the provider. Also, PFFS plan determines how much it will pay doctors, other health care providers, and hospitals and how much you should pay when you get car. The plan may not include prescription drugs, so you may have to enroll in a stand alone part D plan separately.
- Medical Savings Account Plan: This plan combines a high-deductible health plan with a special savings account. Medicare deposits funds that are withdrawn tax free to pay for qualified health care services, so beneficiaries can afford to see any provider they want. More so, when beneficiaries reach their deductible. The plan begins to pay for Medicare covered services.
MEDICARE ADVANTAGE PROS & CONS
Often times people go through the dilemma of deciding which is a better choice; Medicare Advantage or Original Medicare. there’s really no simple answer because Medicare Advantage plans have certain key features that most people find attractive and other unfavourable attributes that may not match one’s preferences.
Here are some pros and cons that may prove useful to intending beneficiaries:
MOST MEDICARE ADVANTAGE PLANS COST LESS: Some Medicare Advantage plans have premiums as low as $0. In this case, the insurer determines the Medicare Advantage Plan’s premium which can vary from one Medicare Advantage plan to another. In most cases, Medicare Advantage plans are less expensive when compared to the same cost for coverage in Original Medicare. However, to get all the benefits of Medicare Advantage with Original Medicare, beneficiaries would need to enroll in a stand-alone Medicare Part D Prescription Drug plan as well as a Medicare Supplement plan.
MEDICARE ADVANTAGE PLANS COORDINATE CARE AMONG HEALTH CARE PROVIDERS: With Medicare advantage plans, beneficiaries stand to get coordinated care from in-network service providers. In this regard, HealthCare providers tend to work together and collaborate on your care, thus minimizing unnecessary tests and lab work.
MEDICARE ADVANTAGE PLANS OFFER SIMPLIFIED CARE: Most Medicare Advantage plans combine Original Medicare with Part D prescription drug coverage, and even added benefits such as, vision, dental and hearing care. With a Medicare Advantage plan, beneficiaries are assigned just one insurer that covers all their healthcare needs, thereby streamlining your healthcare.
HEALTH EQUIPMENTS ARE SOMETIMES COVERED: Some Medicare Advantage plans offer extra coverage for health and fitness equipment and services, such as gym membership, meal subscriptions and telehealth access.
THOSE WITH END STAGE RENAL DISEASE DO NOT QUALIFY: People with chronic illnesses such as renal failure are not allowed to enroll in the plan. People with ERSD can only enroll in the Original Medicare.
MEDICARE ADVANTAGE PLANS’ COVERAGE FOR SOME SERVICES AND PROCEEDURE MAY REQUIRE DOCTOR’S REFERRAL AND PLAN AUTHORIZATION: Medicare Advantage plan tries to avoid the misuse or overuse of healthcare through various means. This could include prior authorization for hospital stays, home health care, medical equipment, and certain complicated procedure. Medicare Advantage also often requires referral from a beneficiaries’ primary care doctor to see a specialist before such service can be paid for. This process can prove costly in emergency situations.
MEDICARE ADVANTAGE PLANS ARE AREA SPECIFIC: Most Medicare Advantage plans only cover for specific regions; they do not have nationwide coverage. For this reason, enrollees must reside in the Medicare Advantage plan’s service area for at least 6 months. For those who divide their time between homes located in different areas, such requirement may be difficult to meet.
AN ENROLEE PLAN COULD STOP PARTICIPATING IN MEDICARE: In a situation where a beneficiary’s plan stops participating in Medicare – which usually happens, such person will have to be enrolled in another Medicare advantage plan or return to Original Medicare.
From the foregoing, Medicare Advantage plan could be just right for an intending enrollee if its healthcare coverage specification matches that of the enrollee. Using a plan finder tool can make this process quite easy as it allows you to quickly see what benefits are offered by different plans and helps you compare between available plans. If you’re looking for specific benefits, however, you can use filters to narrow down the search.