Medicare Advantage
Part C, Also Known as Medicare Advantage
This part of Medicare is the Advantage Plan. It includes the benefits of Part A and Part B and majority of the plans will include Part D, prescription drugs. These are private insurance plans that contract with Medicare to provide you with health insurance coverage. Medicare offsets the cost of the plans, this is why you typically will find $0 premium plans. There often HMO and PPO network options available with maximum out of pocket limits.
The Benefits of Medicare Advantage Plans
Medicare Advantage plans provide the luxury of getting all your coverage options in one plan. They offer flexible plan options such as, PPO, HMO, PFFS, and SNP (Special Needs Plans). You have the ability to save on cost due to some plans having zero dollar premiums and deductibles. Additionally, compared to Original Medicare you have an out-of-pocket maximum that caps your annual cost for covered services.
Some plans can include some of the following benefits, not all benefits are listed:
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Dental, Vision, and Hearing
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Fitness Memberships
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Transportation to doctor visits
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Over-the-counter drugs
Networks
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HMO (Health Maintenance Organization) is a common Medicare Advantage network option that requires a designated PCP (Primary Care Physician) and referrals to see specialists. There is no out-of-network coverage.
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PPO (Preferred Provider Organization) is a common Medicare Advantage network option that does not require a designated PCP (Primary Care Physician). Referrals are not required to see specialists. There is in-network and out-of-network coverage.
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PFFS (Private Fee-For-Service) a type of Medicare Advantage Plan. Referrals and PCP's are not required to see a doctor. You can visit any provider who is eligible to receive payment from Medicare as long as they agree to accept the plan's payment terms and conditions.
Medicare Advantage Eligibility
Medicare Advantage eligibility generally begins when you turn 65. However, individuals who have been receiving Social Security disability benefits for at least 24 months are also eligible. You must be enrolled in Medicare Part A and Part B if you are a US citizen or a permanent resident and have lived in the United States for five continuous years.
Initial Enrollment Period
Your IEP (Initial Enrollment Period) for Medicare spans seven months, beginning three months before the month you turn 65 and ending three months after the month you turn 65. If you're under 65 and receiving Social Security disability benefits, you become eligible for Medicare in the 25th month after starting to receive those benefits. In such a case, you can enroll in an Advantage plan three months prior to your month of eligibility and up to three months after becoming eligible.
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Open Enrollment Period (October 15-December 7)
This is also referred to as the "Annual Enrollment Period". During this time you can switch from Original Medicare to a Medicare Advantage Plan. You can also join, drop, or switch to another Medicare Advantage Plan.
Medicare Advantage Open Enrollment Period (January 1-March31)
If you're already in a Medicare Advantage plan or within the first three months you get on Medicare you can change Medicare Advantage plans during Medicare Advantage OEP.
Special Enrollment Period
There are special circumstances that vary for each person. To find out if you qualify for a special election period, it's best to consult with a licensed Medicare insurance agent (like us!). The most common circumstances include moving outside your current Medicare Advantage plan's service area, qualifying for extra help with prescription drug costs, or transitioning to a nursing home. During a special period, you have the flexibility to make changes to your Advantage plan or switch back to Original Medicare.
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Types of Medicare Advantage Plans
HMO (Health Maintenance Organization)
HMO plans grant you comprehensive health care coverage exclusively from doctors, health care providers, and hospitals within the plan's network. In simpler terms, you're presented with a curated list of approved providers to select from when seeking medical services. However, opting for a provider outside of this network will result in you having to cover the full cost of those services yourself.
PPO (Preferred Provider Organization)
When it comes to additional coverage, Medicare Advantage PPO plans are the top choice for many individuals. The great thing about PPO plans is that you have the freedom to visit your preferred doctors, specialists, and healthcare facilities, regardless of whether they are in your plan's network or not. Another major perk of PPO plans is that you don't need a referral from your primary care doctor to see a specialist.
Keep in mind that PPO plans may have their own monthly premium, excluding the Part B premium. Additionally, there might be deductibles for both the plan itself and the prescription drug coverage. Copayments can vary depending on whether you visit an in-network or out-of-network doctor or specialist. With a Medicare PPO plan, you'll have an in-network maximum amount and an out-of-network maximum amount that represent the most you'll have to pay out-of-pocket.
SNP (Special Needs Plans)
SNP plans are designed exclusively for individuals with specific diseases or conditions, ensuring specialized care from dedicated experts in those areas. These plans offer the significant advantage of comprehensive drug coverage through Medicare Part D. It's important to note that you must have a primary care doctor and obtain a referral when seeking specialized care.
SNP plans cater to those residing in certain institutions, such as nursing homes, or individuals who require nursing care at home. They are also available to those eligible for both Medicare and Medicaid, as well as individuals with specific chronic or disabling conditions. If you meet the eligibility criteria for a Medicare Advantage Special Needs Plan, you have the flexibility to enroll at any time.
PFFS (Private-Fee-For-Service)
PFFS plans have a designated network of providers who have agreed to treat PFFS plan members consistently. It's crucial to note that if you seek non-emergency or non-urgent care services from a provider not in the plan's network, your services may not be covered or your costs could be higher. Some PFFS plans also offer prescription drug coverage. Notably, PFFS plans provide the advantages of not requiring a primary care doctor and not needing a referral to see a specialist.
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