Medicare Advantage plans, also known as Part C plans, are alternatives to Original Medicare and are sold by Medicare-approved private insurance companies. They cover all the benefits under Original Medicare and cover extra services that include, but are not limited to prescription drugs, dental, hearing, and vision care. Most Medicare Advantage Plans include drug coverage plans, also called Part D plans, and in most cases, you’ll need to use healthcare providers who participate in the plan’s network. To be able to enroll in a Medicare Advantage plan, you must first be enrolled in Original Medicare.
Types of Medicare Advantage Plans
Health Maintenance Organization Plans: HMO plans typically limit their coverage to in-network healthcare providers with the exception of emergency care, out-of-area urgent care, and temporary out-of-area dialysis. This means there is a list of health providers to choose from, but you may cover all the out-of-pocket costs for the services if you choose to receive care out-of-network. These plans may also require you to select a primary care physician from one of their networks and get referrals when a specialist is needed. Generally, prescription drugs are covered in HMO Plans but you will need to check this with the plan’s provider.
Preferred Provider Organization Plans: PPO plans offer more flexibility than HMO plans but at a higher cost. Though each PPO plan has a list of in-network providers, you will typically have the option to get healthcare services from out-of-network providers. However, you will pay more for these services. Nevertheless, you will still get more coverage than you would with an HMO plan. Also, you don’t need a referral to go to a specialist, nor are you required to choose a primary care physician.
Private Fee-For-Service Plans: This type of Medicare Advantage plan allows you to keep or choose any healthcare provider as long as they accept the terms of your Medicare Advantage plan. You won’t be required to choose a primary care physician or get referrals to visit a specialist. However, this plan will decide how much they will pay for your services, as well as how much you will pay. Prescription drugs may be covered in PFFS Plans but If your PFFS Plan doesn’t offer drug coverage, you can join a separate Medicare Part D Drug Plan to get coverage.
Special Needs Plans: Medicare Advantage Special Needs Plans are available to individuals with chronic health conditions and specific healthcare needs. These kinds of plans will adjust their benefits, provider choices, and drug formularies to best meet the specific needs of the individuals they serve. These plans will cover everything that Original Medicare does, and they are required to provide prescription drug coverage. The three types of Special Needs Plans are:
- Chronic Condition Special Needs plans
- Institutional Special Needs plans
- Dual Eligible Special Needs plans
Some Special Needs Plans require primary care doctors, and some don’t. This also goes for referrals as some plans require them and some don’t. You will need to check all of this with the plan you choose.
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For Medicare Advantage plans costs vary but if you have a Medicare Advantage program, you must pay your Medicare Part B premiums regularly. However, some Medicare Advantage plans may cover part of this premium.
Some Advantage plans have premiums as low as $0, but the average premium for a Medicare Advantage plan is around $21 per month. There’s also a maximum out-of-pocket limit for Part C plans which varies by plan, thereby reducing the total out-of-pocket costs you’ll cover. Once you pay the plan’s limit, the plan pays 100% of your covered health services for the rest of the calendar year.
Medicare Advantage Eligibility
You are eligible for Medicare Advantage if you:
- You’re a U.S. citizen or lawfully present in the U.S
- You live in the service area of the plan you would like to join.
- You have Medicare Part A and Part B.
Medicare Advantage Enrollment
One of the most important factors by which you become eligible for Medicare Advantage is your enrollment in Original Medicare which must include Part A and Part B coverage. You can enroll in Part C when you enroll in Part B which you can’t drop if you want to use Medicare Advantage. Paying the deductible for Medicare Part B is mandatory and makes you eligible for purchasing Medicare Advantage plans. To enroll in Part C there are a few time periods you need to keep track of as these are key times during which you can enroll, switch or drop plans.
Time periods through the year during which you can enroll or change plans if you already have a Medicare Advantage plan are:
- Initial coverage enrollment period: this time period begins 3 months before your 65th birthday and lasts until 3 months after your 65th birthday.
- Annual enrollment period: this is the most common period to enroll, and it starts on the 15th of October and ends on December 7th. It is important to mention that the plan’s benefits will be effective on the 1st of January.
- Special enrollment period: this time period can be triggered for individuals when special circumstances and events occur such as low-income status, life-changing events, etc.
- Medicare Advantage Open Enrollment Period: this period is active from January 1st until March 31st each year. If you are enrolled in a Medicare Advantage Plan, during this time you can switch to a different Medicare Advantage Plan or switch back to Original Medicare and join a separate Medicare drug plan. It is important to mention that you can only switch plans once during this period.
The Bottom Line
Medicare Advantage plans are a good choice if you want the coverage provided by Original Medicare and the extra benefits that a Medicare Advantage plan can provide.
Our Agents Can Help
If you’re interested in a Medicare Advantage plan, reach out to Better Place Insurance Group and our Florida Medicare Agents! Our goal is to help make Medicare a bit simpler and ease the confusion, and by doing so, we can help you compare plans, coverage, and costs.