Essential Facts about Medicare Advantage Plans

Medicare advantage plans are offered by private insurance companies who have approval from Medicare to provide related benefits. This insurance coverage is much like the PPO or HMO, and is sometimes referred to as Part C. It provides you an option, wherein all your health care needs are covered under one plan, with some extra benefits from Part D.

Benefits Covered under Medicare Advantage Plans

Medicare advantage plans provide cover for hospital insurance and medical insurance covered under Part A and Part B, including urgent care and emergency benefits. Hospice care is the only major benefit not included in the benefits provided by this plan, for which the person has to enroll in original Medicare.

Several plans provide extra coverage like hearing, vision, dental, general check up and other wellness and health programs. Many of them also provide the benefits of prescription drug coverage.

These plans work more like managed care plans, usually as a preferred provider organization or health maintenance organization. As per the rules laid down under this plan, the insured person is required to select a primary care physician (PCP).

The chosen PCP refers the person to see a specialist if need arises, and use only hospitals, doctors, and medical facilities assigned under the health plan’s provider network.

Some insurance companies may be liberal enough to offer these plans as a private-fee-for service plan which allows the insured person to consult a doctor or use a medical facility as per his or her choice.

The person may have to make a copayment for visiting the doctor of his or her choice and not every provider may be willing to provide health care service. But in PFFS, it is not mandatory for the insured person to choose a PCP and no referral is required to consult a specialist.

Medicare Advantage Plan Rates

Medicare pays a fixed amount of money every month to the advantage plan to provide for the care. It is then the responsibility of private insurance company to pay for the insured person’s doctor, hospital and other related health care services.

Although, advantage plan must adhere the guidelines but it can still charge premium and out-of-pocket expenses like doctor visit co-payment, medical equipments coinsurance, and annual deduction for prescription drugs.

The insured person is also responsible for monthly Part B premium which is charged from the social security account. For example: Jack M living in Massachusetts is enrolled in a Medicare advantage plan from Fallon Health Community, which is one of the top rated health plan in the country. The person also has an HMO plan along with drug coverage. He pays $208 as part of monthly premium towards the plan.

Apart from this, Jack is also required to pay fifteen dollars as co-pay for each visit he makes to PCP. There is ten percent surcharge as coinsurance for durable medical equipments, plus three hundred and ten dollars as annual deduction for prescription medication.

Medicare Advantage Plans Enrollment Process

People who are already enrolled in Part A and Part B can also join advantage plan provided that the area in which they live accepts enrollment for new members. Some plans are only available in certain counties of a given state and the applicant must be a resident of that county in which the plan is offered.

Local insurance companies hold seminar to promote their products and people can get all the relevant information and also enroll in the advantage plan at that time. A person can also get in touch with a private insurance company and get the details of the plan any time. A lot of information can also be had from the website of the national insurance provider.

One must look for the plans provided in his or her respective area. At times the plan may look quite beneficial but it may turn out to be nothing if it is not available in your area. People who are already enrolled in the plan and looking forward to switch to a new one, just have to enroll in the new plan and they are automatically disembroiled from the older plan. There will be no lapse in the coverage while doing so.

There is however, a limitation on when can a person join, drop or switch the plans. As per the regulations, a person can join this plan during the first enrollment period of Medicare or when he first becomes eligible. The best part of enrolling in this period is that your application cannot be turned down due to health concerns.

Disabled people can enroll in advantage plan after twenty five months of disability; a person can also re-elect to drop or switch from this plan during the open enrollment period.

Medicare Advantage Plans – Things one should know

People must understand the difference between original Medicare and the Medicare advantage plans before they fill the application form. Here are some important points:

  • Insured person must stay within the rules, for example choose a PCP and only use health care services assigned under the advantage plan HMO.
  • People with pre-existing conditions can also join and there is no waiting period.
  • A person can join another plan or switch back to original Medicare in case your advantage plan no longer forms part of Medicare.
  • In case these plans do not cover prescription drug, the person is free to join Part D plan in his or her state. However, as per Medicare rules, if the respective plan of a person also covers for prescription drug and he or she enrolls in Medicare prescription drug plan. In such case the benefits are nullified and he or she will be automatically returned to the original plan.
  • There is no need to purchase Medicare supplemental insurance as long as the person is enrolled in an advantage plan. As a matter of fact, it is illegal to sell and enroll in both the plans together. All the benefits of a Medigap policy are there in an advantage plan along with coverage for copayments, deductibles and coinsurance.