Medicare Advantage Plans

Medicare Advantage plans are health plan options that are approved by Medicare and run by private insurance companies. They are part of the Medicare program and are considered Part C of Medicare.

When you join a Medicare Advantage (MA) plan, you are still in Medicare. The plan provides all of your Part A (hospital) and Part B (medical) coverage and must cover medically necessary services. They generally offer extra benefits and some may include Part D drug plan benefits.

Medicare pays an amount of money each month to the company to provide your health care services. There are some Medicare Advantage plans with $0 premium to the member. This is possible because Medicare is paying money to the company each month on your behalf. You can join the plan if:

1. You live in the plan's service area
2. You have Medicare Part A and Part B
3. You don't have End-Stage Renal Disease (ESRD)

Medicare Advantage Plans Have a Number of Differences from the Original Medicare Plan

• You still pay your Part B premium
• You will usually pay a co-pay for services you get
• You don't need to buy a Medigap or Medicare Supplement policy
• Wellness benefits (annual physicals) are usually included in the plan
• There may be extra benefits like vision, dental and hearing coverage
• Some plans have a network of doctors
• Some plans include a Part D drug plan benefit in them (you won't need a separate Part D plan)
• There are out-of-pocket maximums for the plan
• Lower co-payments and deductibles than Original Medicare (without a Medicare supplement)

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Types of Medicare Advantage Plans

There are three types of Medicare Advantage Plans. Since each plan can vary, it is important you read the plan materials carefully.

HMO - Health Maintenance Organization. In most cases, these plans will include the prescription drug coverage and that is included in the premium. You will need to choose a primary care doctor and get a referral before you see any other health care provider. Except for emergencies, you generally must receive your care from doctors in the plan's network. If you go out of network, you may have to pay 100% of the cost. This can be the most restrictive option. If you choose this option, we recommend you make sure all your doctors participate in the HMO.

PPO - Preferred Provider Organization. Most of these plans will include prescription drug coverage and that is included in your premium. There is a network of doctors and hospitals. If you choose a doctor in the network, your cost is less than if you go out of network. There may be deductibles that apply if you go out of network. No referrals are needed to see doctors other than your primary care doctor. We recommend that you make sure all your doctors are in the plan's network to keep your costs the lowest. The network of doctors may vary if you have a local PPO verses a regional PPO.

PFFS – Private Fee For Service. this is the most flexible of all the Medicare Advantage plans. You can see any doctor or hospital as long as they agree to accept payment from the plan. Some include prescription drug coverage in the premium (in that case you do not need a separate Part D drug plan) but many do not. Many providers accept payment from the plan as:

1. They get paid the same reimbursement as Medicare
2. They only have to bill one company (not Medicare and the Medicare Supplement company)
3. They are usually paid within 15 to 30 days
4. The system for reimbursement is the same as that used for Medicare
5. The patient pays a co-pay at the time of service and the provider agrees to accept that as payment in full.

PFFS plans do not require providers to join a network. There are no lists of doctors that members need to use. Providers are considered "deemed" participants of a plan if they:

1. Know in advance of providing services that a Medicare beneficiary is a member of the plan. Members are told that they should show their ID card each and every time they visit a provider (doctor or hospital).
2. Have a reasonable opportunity to obtain the term and conditions of the plan prior to providing services. These are provided via a website and provider services number (on the back of the member's card).
3. Subsequently provide services to that member.

You have an opportunity each year to change your Medicare Advantage plan during the annual enrollment period (November 15 to December 31). Just like with the prescription drug plan. We recommend you re-evaluate your plan yearly. If you live in Indiana or Kentucky, we can help you do that. Contact us for information.

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