Medicare Advantage Plan (Part C) is a health insurance plan that is used as an alternative to Original Medicare (Medicare Part A and B). Medicare Advantage plan does not only cover the health care services offered by Original Medicare but it also includes benefits like dental, vision, hearing, gym membership and some prescription drug coverage. Some Medicare Advantage Plans may offer less to no premium, lower copays and out-of-pocket costs.
Types of Medicare Advantage Plans:
- HMO (Health Maintenance Organization plan) – lets you see doctors and other health professionals who participate in its provider network. Out-of-network are normally not covered unless it’s an urgent or emergency visit.
- PPO (Preferred Provider Organization plan) – this is the plan for you if you are looking for more flexibility because the plan covers both in-network and out-of-network providers. This plan allows you to visit healthcare provider you prefer without requiring a referral from a primary care physician. But note, out-of-network providers may cost you higher copay, coinsurance and out-of-pocket costs.
- PFFS (Private Fee-for-Service plan) – this plan determines how much it will pay providers and how much you need to pay when you receive care. The treating doctor has to accept the plan’s payment terms and agree to treat you. If the doctor doesn’t agree to those terms, then the PFFS plan will not cover services through that doctor.
- SNP (Special Needs Plans) – this plan is for people who have certain special needs. The three different SNP plans cover Medicare beneficiaries living in institutions, Dual Eligible beneficiaries and those with chronic conditions such as diabetes, End Stage Renal Disease (ESRD), or HIV/AIDS.
- HMO-POS (Health Maintenance Organization – Point of Service plan) – this plan covers both in-network and out-of-network health services at different rates. You will pay less out-of-pocket when you go to in-network hospitals, doctors and other health care providers.
- MSA (Medical Savings Account plan) – this plan includes both a high-deductible insurance plan and a medical savings account that you can use to help you pay for health care services. The money deposited on your MSA is tax-free as long as you use it on IRS-qualified medical expenses.
What do Medicare Advantage Plans cover?
Medicare Advantage Plans cover all of the services that Original Medicare (Medicare Part A and B) covers except for hospice care. The good thing is, Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan.
Aside from covering Part A (Hospital Insurance) and Part B (Medical Insurance), Medicare Advantage Plans offer extra benefits such as dental, vision, hearing and sometimes even gym membership.
Most Medicare Advantage Plans include Medicare Part D (Prescription drug coverage) too.
Also, Medicare Advantage Plans cover emergency and urgent care even if you are outside your plan’s service area.
How much do Medicare Advantage Plans Cost?
The cost of Medicare Advantage Plans vary depending on the type of plan or county you live in. Plan decides on how much you’ll pay for health care services you get. Each year, the plan may change out-of-pocket cost and covered benefits.
Medicare Advantage Plan (Part C) out-of-pocket costs depend on:
- Monthly premium the plan charges. Monthly premiums range from $0 to as high as around $300.
- Deductibles the plan charges
- Copay or coinsurance for doctor visits or other covered services.
- Out-of-pocket costs for all medical services
- Type of health care services you need and how often you get them.
- Whether you have Medicaid or get federal or state-run assistance program.
Who can sign up for Medicare Advantage Plans?
To sign up for Medicare Advantage Plan, you must have both Medicare Part A and B and live in the plan’s service area. Unfortunately, if you have end-stage renal disease (ESRD), you can’t join a Medicare Advantage Plan.
Note: In most cases, you can’t enroll in a Medicare Advantage plan anytime you’d like except if you qualify for Special Enrollment Period (SEP).
Medicare Advantage Special Election Period (SEP):
You may sign up or change your Medicare Advantage Plan outside of the Open Enrollment Period if you qualify for Special Enrollment Period.
Here are certain life events listed on medicare.gov that may allow you to enroll or change plan:
You move to a new location
- Either you moved to a new address that is not in your plan’s service area or your new address is still in plan’s service area but there are new options available
- Moved into or out of institutions like skilled nursing facility or long-term care hospital
- Moved back to the US after living in different country
- Released from jail
You lose your current coverage
- You are no longer eligible for Medicaid
- Lost coverage from employer or union (including COBRA coverage)
- Involuntarily lose of Medicare drug coverage or other creditable drug coverage
- Dropped your coverage in Program of All-inclusive Care for the Elderly (PACE)
You have a chance to get other coverage
- Eligible in other coverage offered by your employer or union
- Have or your enrolling in other drug coverage as good as Medicare prescription drug coverage (like TRICARE or VA coverage).
- Enrolled in a Program of All-inclusive Care for the Elderly (PACE) plan.
Your plan changes its contract with Medicare
- Medicare terminates your plan’s contract
- Your Medicare Advantage Plan, Medicare Prescription Drug Plan, or Medicare Cost Plans contract with Medicare isn’t renewed
Other special situations
- When you are eligible for both Medicare and Medicaid
- If you qualify for Extra Help paying for Medicare prescription drug coverage
- If you are enrolled in a State Pharmaceutical Assistance Program (SPAP) or lose SPAP eligibility
- When you dropped a Medigap policy the first time you joined a Medicare Advantage Plan
- If you have a severe or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan (SNP) available or have SNP but you no longer have a condition that qualifies for it.
- You weren’t informed that private drug coverage you have was not as good as Medicare drug coverage
Other Medicare Advantage Enrollment Period:
- Initial Enrollment Period (IEP) – time when you are first eligible for Medicare A and B. It starts 3 months before the month of your birthday and 3 months after.
- Annual Enrollment Period – All Medicare beneficiaries can enroll, change or switch plans during this period. It starts October 15 – December 7.
- Open Enrollment Period – this period is new this year 2019. Anyone who’s currently enrolled with Medicare Advantage can switch to another Medicare Advantage, go back to Original Medicare with or without prescriptions and Medicare supplement.
Compare Medicare Advantage plans in Washington
In choosing Medicare Advantage plans, here are the things you need to look into:
- Plan monthly premium – There are some plans that offers low to zero premium. However, you still need to check other costs such as deductibles, copays and out-of-pocket costs.
- Additional benefits – Some Medicare Advantage plans cover dental, vision, hearing and gym membership. Different plans offer different benefits so choose a plan that best fit your needs.
- Preferred Provider – If you have a preferred provider or clinic, check if they are covered within the plan’s network.
- Prescription drugs – List all medications you take and check on plan’s formulary to make sure they are covered.
Get FREE help from a licensed insurance agency like Health Plans in Washington. For over a decade, we’ve been helping Medicare beneficiaries in Washington compare different Medicare Advantage Plans that fit their needs and budget. You can call us at 360-787-1048 or 206-801-3958.