Understanding Medicare Part C- Advantage Plans

Medicare Part C is also known as Medicare Advantage. Some beneficiaries choose a Medicare Advantage plan because it is a private plan that offers Part A, Part B, and usually prescription drug coverage in one. It has its pros and cons like every Medicare plan, but many people like having all of the benefits provided by just one insurance provider.

Types of Medicare Advantage Plans in 2020

There are different types of Medicare Advantage plans and each one has its own rules. Here are the four main types of Advantage Plans.

HMOs- Health Maintenance Organization Plans

When you’re a member of an HMO, you must get your healthcare from approved providers who are a part of the plan. (You can go anywhere for emergency care, out-of-area urgent care, and out-of-area dialysis.) With this plan, it is important to see what specialty hospitals you have access to.

Part D prescription drug coverage is sometimes covered in HMO plans, so be sure to double check with your plan if you do want it.

You should choose a PCP when you sign up for an HMO or choose a plan that has your PCP in-network.. They will be your go-to health professional and provide needed referrals if you need to see a specialist.

Be sure to follow the plan’s rules so you don’t end up paying full cost for a service. Sometimes you must have a procedure pro-approved. Other times certain doctors aren’t covered and you have to pay. It never hurts to check with the plan ahead of time (except in an emergency).

PPOs- Preferred Provider Organization Plans

A PPO is exactly what it sounds like- there are preferred doctors and hospitals that will cost you less, but you can go to other providers if you wish. It will just cost you more.

PFFS- Private Fee-For-Service Plans

Your out-of-pocket costs will be lower if you choose to get care from in-network providers. There may be additional out-of-network providers that accept your PFFS terms that you can get care from, it just may cost you more.

Be sure to check with your providers at every visit to be sure they will still treat you under your PFFS plan. Agreements can change and you could owe more money than you expected.

SNPs- Special Needs Plans 

Special Needs Plans are plans created to serve a specific group of people who have the same disease or other commonalities. They contract with drug companies and specialists that serve their members. Common qualifications include living in a nursing facility, having dementia, diabetes, End-Stage Renal Disease, HIV/Aids, and some other diseases.

HMOPPOPFFSSNP
Must go to approved providers (besides emergencies)YesNo, but out-of-network costs more.You can see anyone who agrees to treat you under the plan.Yes
Part D CoveredSometimes. Usually. Sometimes.Yes
If prescriptions aren’t included, can I get a separate Part D Plan?NoNoYesx
Choose a PCPYesNoNoSometimes. A care coordinator may also be used.
Referral needed (besides scheduled testing like mammograms and Pap tests)YesNot usuallyNoYes

How much does Medicare Part C cost?

Part C ( an Advantage plan) has its costs determined by private insurance companies. You can choose from a variety of Advantage plans, and one of your considerations should be cost. Plans differ in their premium amount, deductibles, copays, and coinsurance. You’ll want to compare important aspects of each plan before you decide on one. If you need help, that’s what we’re here for!

Medicare Part C- Medicare Advantage Plans Pros and Cons

ProsCons
All benefits are provided by one company.Your provider choices are limited to those who have agreements with your plan.
Additional coverage can be offered- like hearing, dental, vision, or fitness programs.Coverage areas apply, so you may not be covered if you’re travelling (you’re generally covered for urgent care and ER).
Out-of-pocket maximums apply, so once you hit a predetermined cost, you won’t pay any more copays or coinsurance that year.Plans can stop working with providers and providers can stop working with any plan. This can happen during the year, so you may have to look for a new doctor at any point in time.

Can I switch from Medicare Advantage to Original Medicare?

You can switch any type of plan during the open enrollment period (January 1 to March 31 every year). After you choose the plan you want, your coverage will start the first day of the next month.

What’s the difference between an HMO and a PPO?

An HMO (or Health Maintenance Organization) has a list of providers you can see, while a PPO (Preferred Provider Organization) simply has providers that will be cheaper for you to see. Both types of Advantage plans can cover prescription drug costs, but you can’t add on Part D prescription coverage. 

HMOs are usually chosen by people who do not mind a local network with a lower max-out-of-pocket and need preventative coverage options.

PPOs can work well for people who need to see a lot of specialists, because they can get coverage from both in- and out-of-network providers. PPOs are generally more expensive and have a higher max-out-of-pocket, but offer more flexibility.

What does in-network mean?

Some Medicare Advantage plans let you go to different doctors depending on which they have in-network. What is in-network for one plan, may not be in-network for another.

Can I get a Medicare Advantage Plan if I have a preexisting condition?

Yes, you can enroll in a Medicare Advantage plan if you have a preexisting condition. The only exception is End-Stage-Renal-Disease.
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You can sign up for a Medicare Advantage plan by contacting us to set up a no-cost consultation. We will show you your plan options and help you understand what makes the right plan for your situation.

Medicare Advantage plans have more moving parts than a Medicare Supplement plan. If you are thinking about choosing an Advantage plan, we highly suggest you speak to a broker- if not us, please use someone qualified to help you.

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Adam works with Medicare clients to answer questions, assist with enrollment, and run plan comparisons to find the right one for your needs.

He’s also an expert in Dual Enrollment for those on both Medicare and Medicaid.

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