MEDICARE ADVANTAGE

Medicare Part C plans are usually referred to as “Medicare Advantage” plans. All Medicare Advantage plans are run by private companies, and they all combine coverage for hospital stays with coverage for doctor visits. You can choose a plan that includes prescription drug coverage, often at no additional premium, or you can choose a plan without prescription drug coverage.

Medicare Advantage expands health care options for Medicare Beneficiaries. With Medicare Advantage (also called Medicare Part C), you can choose from new ways in which to receive your Medicare benefits.

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    1. Original Medicare: Original Medicare will always be available.  If you want to continue receiving your benefits this way, then you do not have to do anything.

    2. HMO: This is a managed care plan with a network of providers who contract with an insurance company.  You choose a primary care physician who coordinates your care.  You agree to follow the rules of the HMO and use the HMO's providers.

    3. HMO with Point-of-Service (HMO w/pos): This is similar to the Medicare Advantage HMO, except you can use providers outside of the network.  However, you will pay higher deductibles and copayments when you go outside of the network.

    4. Preferred Provider Organization (PPO): This is another managed care plan.  It is formed by a group of doctors, hospitals, and other providers who contract with an insurance company.  You do not have to choose a primary care physician.  You can go outside of the network, but you will pay higher deductibles and copayments when you do.

    5. Provider Sponsored Organization (PSO): This is a managed care plan with a network of providers.  The providers administer the plan and take the financial risk.  You choose a primary care physician and agree to use plan providers.  Most services will be provided by the network.

    6. Private Fee for Service Plans (PFFS): This is an insurance plan, not a managed care plan.  The plan, not Medicare, sets the fee schedule for providers, but providers can bill up to 15% more.  You see any providers you choose, as long as the provider agrees to accept the payment schedule.  Medical necessity is determined by the plan.  The plan does not have to have a quality assurance program.

    7. Religious Fraternal Benefit Society Plans: This is one of the managed care plan types (HMO, HMO w/pos, PPO, PSO) which is formed by a religious or fraternal organization.  These plans may restrict enrollment to members of their organization.

    8. Medical Savings Accounts (MSA): This is a health insurance policy with a high deductible ($3,000) combined with a savings account ($2,000). Medicare pays the insurance policy premium and deposits money into your MSA each month. You can use the money in your MSA to pay your medical costs (tax free). You have free choice of providers. The providers have no limit on what they charge.

    1. All plans have a contract with the Centers for Medicare and Medicaid Services (Medicare).

    2. The plan must enroll anyone in the service area that has Part A and Part B, except for end-stage renal disease patients.

    3. Each plan must offer an annual enrollment period.

    4. You must pay your Medicare Part B premium.

    5. You pay any plan premium, deductibles, or copayments.

    6. All plans may provide additional benefits or services not covered by Medicare.

    7. There is usually less paperwork for you.

    8. The Centers for Medicare and Medicaid Services (Medicare) pays the plan a set amount for each month that a beneficiary is enrolled.

    9. The Centers for Medicare and Medicaid Services monitors appeals and marketing plans. All plans, except for Private Fee-for-Service, must have a quality assurance program.

  • If you meet the following requirements, the Medicare Advantage plan must enroll you.

    1. You may be under 65 and you cannot be denied coverage due to pre-existing conditions.

    2. You have Medicare Part A and Part B.

    3. You pay the Medicare Part B premium.

    4. You live in a county serviced by the plan.

    5. You pay the plan's monthly premium.

    6. You are not receiving Medicare due to end-stage kidney disease.

    Another type of Medicare Managed Health Maintenance Organization is a Cost Contract HMO. These plans have different requirements for enrollment.

    1. You have Medicare Part A and Part B, or only Part B.

    2. You pay the Medicare Part B premium.

    3. You live in a county serviced by the plan.

    4. You pay the plan's monthly premium.

    5. You are not receiving Medicare due to end-stage kidney disease, and you are not in the Medicare Hospice program.