MEDICARE ADVANTAGE

Things You Should Know

So, what exactly is a Medicare Advantage Plan?

A Medicare Advantage Plan some call Part C combines Medicare Part A (hospital coverage) and Part B (medical coverage) and can also include Part D (prescription drug coverage ).

To qualify consumers must have Medicare Parts A and B. Consumers remain a part of the Original Medicare Program after enrollment, but the Medicare Advantage Plan provides the Medicare benefits directly to the consumer. The Plan is an individual plan, so a consumer’s spouse must enroll separately.

There Are Several Plan Types, Including:

1

Health Maintenance Organizations (HMOs)

Consumers select a Primary Care Physician (PCP) from contracted network at time of enrollment. PCP coordinates care with specialists and hospitals. (Referrals to specialists are not required on some plans).

2

Preferred Provider Organizations (PPOs)

Consumers should select a PCP for in-network benefits at time of enrollment. PPO utilizes an existing contracted network for in-network services. It is not the same provider network as the HMO network, although there can be overlap.

3

Point of Service

(POS)

(POS plans are HMO plans with some benefits also covered out-of-network). Consumers select a PCP at time of enrollment. POS utilizes an existing contracted HMO provider network for in-network services.

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Additionally...

Consumers can elect an HMO, POS or PPO Medicare Advantage Plan without Medicare Part D coverage, if available, but they cannot buy a separate Part D plan in this case. Consumers will receive an Outbound Enrollment and Verification (OEV) telephone call. The consumer may have to pay a penalty if they delay enrollment in a Part D plan.

LET'S LOOK CLOSER: Medicare Advantage -Health Maintenance Organizations (HMO)

Consumers must receive services inside the contracted network in order for them to be covered (except for emergency, urgent, and renal dialysis care). HMOs have specific provider network limitations. HMO Plans offer a great value for consumers who will see in-network providers.

LET'S LOOK CLOSER: Medicare Advantage – Preferred Provider Organizations (PPO) Local or (RPPO) Regional

For all services covered in-network, consumers may also seek these services outside the contracted network (usually at a higher cost). All plans are required to cover the same services out-of-network that they cover in-network. All plans include national out-of-network coverage. PPO Plans offer the freedom to see providers of choice (as long as the provider is willing to accept the plan) with optimal benefits for seeing providers in network.

LET'S LOOK CLOSER: Medicare Advantage – Point of Service (POS)

Consumers may seek certain medical services at higher cost). Plan benefits may vary in what is covered out-of-network. For example, a plan may only cover a few services out-of-network, such as inpatient hospital and skilled nursing facility care, while another plan may cover almost all services that are covered in-network on an out-of-network basis as well.

Depending on the plan, there may be some limitations by county or state on out-of-network coverage. POS Plans offer the benefits of an HMO for in-network services as well as some flexibility to go out-of-network when desired, (generally at a higher cost).

Other Things to Note

All Medicare Advantage plans have out-of-pocket (maximum) allows members to manage their health care expenses with greater confidence. If you receive financial assistance i.e. your state low income subsidy and related programs part if not all of your out-of-pocket is covered at that program guide lines, that could include (prescription drug coverage).