Understand Medicare Part C - Medicare advantage

Part C – Medicare Advantage


MA is a program through which organizations that contract with CMS furnish or arrange for the provision of health care services to Medicare beneficiaries who

: Are entitled to Part A and enrolled in Part B
; Permanently reside in the service area of the MA Plan
; and Elect to enroll in a MA Plan.

Individuals with ESRD are generally excluded from enrolling in MA Plans.


Since 2006, beneficiaries have been able to enroll in regional Preferred Provider Organization (PPO) Plans throughout the U.S. In addition, beneficiaries are able to choose options such as Private Fee-for-Service Plans (PFFS), Health Maintenance Organizations, local PPOs (currently the most popular type of employer-sponsored plan), and Medicare Medical Savings Account (MSA) Plans (combines a high-deductible health plan with a MSA).

MA plans may also offer Medicare prescription drug benefits. Individuals enrolled in MA plans must receive their Medicare prescription drug benefits from their MA plan, except for MA PFFS plans that do not include drug benefits.

Medicare beneficiaries may choose to join or leave a MA Plan during one of the following election periods

: Initial Coverage Election Period, which begins three months immediately before the individual’s entitlement to both Medicare Part A and Part B and ends on the later of either the last day of the month preceding entitlement to both Part A and Part B or the last day of the individual’s Part B IEP. If the beneficiary chooses to join a Medicare health plan during this period, the Plan must accept him or her unless the Plan has reached its member limit


. Annual Coordinated Election Period (AEP), which occurs each year between November 15 and December 31. The Plan must accept all enrollments during this time unless it has reached its member limits.


 SEP, when, under certain circumstances, the beneficiary may change MA Plans or return to the Original Medicare Plan.




 Open Enrollment Period (OEP), during which time the beneficiary may leave or join another MA Plan if it is open and accepting new members. Elections made during this period must be made to the same type of plan (regarding Medicare prescription drug coverage) in which the individual is already enrolled. The OEP occurs from January 1 through March 31 of every year. If a plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.

What you Pay Medicare Part C Advantage Plan

Your out-of-pocket costs in a Medicare Advantage Plan depend on the following:

■Whether the plan charges a monthly premium in addition to your Part B premium.

■Whether the plan pays any of the monthly Part B premium. Some plans offer this option, usually for an extra cost.

■Whether the plan has a yearly deductible or any additional deductibles.

■ How much you pay for each visit or service (copayments).

■ The type of health care services you need and how often you get them.

■Whether you follow the plan’s rules, like using network providers.

■Whether you need extra coverage and what the plan charges for it.



If you have limited income and resources, you may qualify for the following:

■ Extra Help paying your Part D premium and other prescription drug coverage costs.
■ Help from your state to pay your Part B premium.

■Whether the plan has a yearly limit on your out-of-pocket costs for all medical services.

How Do Medicare Advantage Plans (Mcr Part - C) Work? Q & A

Can I get my health care from any doctor or hospital?

HMO Plan : No. You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services usually for a higher cost.

PPO Plan : Yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.



Are prescription drugs covered?

HMO Plan : In most cases, yes. Ask the plan. If you want drug coverage, you must join an HMO Plan that offers prescription drug coverage.

PPO Plan : In most cases, yes. Ask the plan. If you want drug coverage, you must join a PPO Plan that offers prescription drug coverage.



Do I need to choose a primary care doctor?

HMO Plan : In most cases, yes.

PPO Plan : No.


Do I have to get a referral to see a specialist?

HMO Plan : In most cases, yes. Yearly screening mammograms and in-network Pap tests and pelvic exams (at least every other year) don’t require a referral.

PPO Plan : No.


What else do I need to know about this type of plan?

HMO Plan :
■ If your doctor leaves the plan, your plan will notify you. You can choose another doctor in the plan.
■ If you get health care outside the plan’s network, you may have to pay the full cost.
■ It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.


PPO Plan :
■ There are two types of PPOs— Regional PPOs and Local PPOs.
■ Regional PPOs serve one of 26 regions set by Medicare.
■ Local PPOs serve the counties the PPO Plan chooses to include in its service area.

More About Medicare Advantage Plans (Medicare Part C)

As with Original Medicare, you still have Medicare rights and protections, including the right to appeal.

■ Check with the plan before you get a service to find out whether they will cover the service and what your costs may be.

■ You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan.

■ You can join a Medicare Advantage Plan even if you have a pre-existing condition, except for End-Stage Renal Disease.

■ You can only join a plan at certain times during the year. In most cases, you are enrolled in a plan for a year.

■ If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan.

■ If the plan decides to stop participating in Medicare, you will have to join another Medicare health plan or return to Original Medicare.


■ You usually get prescription drug coverage (Part D) through the plan. If you are in a Medicare Advantage Plan that includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you will be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.

■ You don’t need to buy (and can’t be sold) a Medigap (Medicare Supplement Insurance) policy while you are in a Medicare Advantage Plan. It won’t cover your Medicare Advantage Plan
deductibles, copayment, or coinsurance.

Medicare Advantage Plans (Part - C) include the following:

Medicare Advantage Plans (Part - C) include the following:

■ Health Maintenance Organization (HMO) Plans.
■ Preferred Provider Organization (PPO) Plans.
■ Private Fee-for-Service (PFFS) Plans.
■Medical Savings Account (MSA) Plans.
■ Special Needs Plans (SNP).

There are other less common types of Medicare Advantage Plans that may be available:

■ Point of Service (POS) Plans—Similar to HMOs, but you may be able to get some services out-of-network for a higher cost.
■ Provider Sponsored Organizations (PSOs)—Plans run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan.


Not all Medicare Advantage Plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs.

Medicare prescription coverage.

Eligibility for Part C

If you join Part C, you will still be in the Medicare Program and will have complete Part A and B coverage. You will continue to have Medicare rights and protection and in most cases, you will have prescription drug coverage (Part D) included as well.

You can join Part C if you reside in the service area where you wish to join, if you already have Medicare Part A and B, and if you do not have End-Stage Renal Disease (with minor exceptions).

Part C is really not that complicated once you understand it all. Before you decide to get health care insurance, it is a good idea to make sure you have a clear understanding of the coverage and premiums. This is not guesswork; don't be afraid to ask questions. A Medicare representative can help you find the answers

Do You Need Prescription Drug Coverage?

Most Part C plans already include prescription drug coverage (Part D). If your plan offers drug coverage, you have to take it. If you have a stand-alone drug plan, and your Medicare Advantage Plan already has one, you will not be able to keep the Part C coverage. If you already have a prescription drug coverage, then you may choose a plan that does not have the drug plan included.
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What Medicare Advantage (Part C) Plans are available?

There are several plans available for Medicare Advantage. The Part C plans include the following:

*Medicare Preferred Provider Organization (PPO) - You are able to see any doctor or specialist that you choose. If they are not in your PPO network, your cost will increase. You usually can see a specialist without a referral.

*Medicare Health Maintenance Organizations (HMO) - You are able to visit doctors in the HMO network only. In most cases, you will be required to have a referral to visit a specialist.

*Medicare Private Fee-for-Service (PFFS) - You are able to see any doctor or specialist, but they must be willing to accept the PFFS's fees, terms, and conditions. You do not have to have a referral to see a specialist.

*Medicare Special Needs - These plans are designed for people with certain chronic diseases or other special health needs. These plans must include Part A, Part B, and Part D coverage.

*Medicare Medical Savings Account (MSA) - There are two parts to this plan:

(1) A high-deductible plan with which coverage won't begin until the annual deductible is met.

(2) A savings account plan where Medicare deposits money for you to use for health care costs.

Medicare part C - what it is

Explanation of Medicare Part C

When considering your Medicare options, it is easy to get confused and overwhelmed. Relax and take one section at a time to gain an overall understanding. Knowing what Medicare is and how it works will help you to make the best decision. One option is called Part C, or Medicare Advantage Plan (like HMO or PPO).

 

What is Part C?

 Medicare Part C combines your Part A and Part B options and must cover all medically needed services. The difference is that private insurance companies that are approved by Medicare provide this type of coverage. In most cases, Part C is a lower-cost alternative to the Original Medicare Plan, and providers usually offer extra benefits and include prescription drug coverage (Part D).

Part C plans often have networks, and you must use the doctors or hospitals that belong to the plan. These plans help you coordinate and manage your overall care. Part C includes specialized care for people who need a large amount of health care services. If you find yourself needing medical attention while traveling out of your plan coverage area, you will still be covered for emergency or urgent care services.