Medicare Advantage (Medicare Part C)

How do medicare Advantage Plans Work?

Medicare Advantage plans work in several different ways and each plan differs in benefits.  An advantage plan, also known as “Part C” plans, which people get confused with Medicare Plan C.  Plans and Parts are completely different.  Medicare Part C combines Medicare Part A and Part B benefits in an all in one alternative to Original Medicare, but can provide additional benefits as well.  

All Part C plans are offered by Medicare-approved private companies that must follow rules set by Medicare. Some of the most popular carriers include Humana, Aetna, AARP United Healthcare, Cigna, Wellcare and more. Benefits and availability vary by location. 

Most Medicare Advantage Plans include drug coverage (Part D). In many cases, you’ll need to use health care providers who participate in the plan’s network and service area for the lowest costs. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services, to help protect you from unexpected costs.

What should I know about Medicare Advantage Plans?

To join a Medicare Advantage Plan: You must have Part A and Part B and you must live in the plans service area.

What are the different types of Medicare Advantage Plans?

There are several types of plans. The most commonly known plans are HMO, PPO, PFFS and SNPs.

What is an HMO Plan?

An HMO plan is a popular managed care plan that contracts with doctors and providers in your area. Some plans offer premiums as low as $0 monthly. In general, you must get your care from the providers that are in the plan’s network, except for in emergency situations.

Do I need to choose a primary doctor in an HMO Plan?

Yes. In an HMO plan, you must choose a primary care provider.

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

In most cases, a referral is required to see a specialist. However, certain services such as mammograms and yearly screenings do not require a referral.

Can I get healthcare from any doctor or provider?

No, you generally must get care from doctors and healthcare providers that are in the plan’s network. (except for emergecy situations or urgertly needed care).

What is a PPO Plan?

A PPO is also a plan that has a network of health providers, but you are not required to choose a primary care physician and do not need a refferal to see a specialist. However, you will generally pay lower co-pays if you see providers in network and higher co-pays out of network.

Do I need to choose a primary doctor in an PPO Plan?

No. A PPO plan does not require you to choose a primary care doctor.

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

No, you can see a specialist without the need of a referral. However, by using an in network provider, your cost will be lower than using an out of network provider.

Can I get healthcare from any doctor or provider?

Yes, these plans have doctors, specialists and other health care providers you can use that are in network. You can also visit out of network providers for services, but usually at a higher cost.

What is a Private Fee for Service Plan?

A Private Fee for Service Plan is another type of Medicare Avantage plan that is offered in select areas. With this type of plan, you agree to pay the plan’s premiums, co-pays and coinsurance for services that are outlined in the plan. It’s different from an HMO or PPO plan because you are not limited to a network of providers.

However the provider must agree to accept the plan’s payment terms and conditions before assisting with your care.

Do I need to choose a primary doctor in a Private Fee for Service Plan?

No. In a PFFS plan, you do not need to choose a primary care provider.

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

No, a referral is not needed.

Can I get healthcare from any doctor or provider?

You can see any doctor in the country who particiates in Medicare, agrees to treat you and is willing to accept the plans terms and conditions.

What are Special Need Plans?

Special Need Plans are types of Medicare Advantage plans that provide managed care to beneficiaries with specific conditions and illneseses. These health conditions include and are not limited to cancer, chronic illnesses and chronic heart failure. SNP plans are also designed for enrollees that are eligible for both Medicare and Medicaid.

Do I need to choose a primary doctor in a Special Need Plan?

Yes. In an SNP plan, you generally must choose a primary care provider.

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

In most cases, a referral is required to see a specialist. However, certain services such as mammograms and yearly screenings do not require a referral.

Can I get healthcare from any doctor or provider?

Some SNP plans cover services out of network and some do not. It’s important to check with your specific plan.

What do Medicare Advantage Plans Cover?

Plans must cover all emergency and urgent care, and almost all medically necessary services Original Medicare covers.

What benefits do Medicare Advantage Plans offer?

Most Medicare Advantage Plans offer coverage for things Original Medicare doesn’t cover such as:

  • Dental
  • Vision
  • Hearing
  • Fitness Programs
  • Transportation to Doctor
  • Visits
  • Prescription Drug Coverage

 

Some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness. Plans can also tailor their benefit packages to offer these benefits to certain chronically-ill enrollees.

It’s always important to check with the plan to see what benefits it offers, any limitations and to see if you qualify.
With all this in mind, we understand finding the right health plan is a tough task for many beneficiaries. We hear this alot and trying to learn everything on your own could be a bit overwelming.

Thankfully, we are here to be you guide and help make things easy.

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