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Part C: Medicare Advantage

What is Medicare Part C?

Medicare Part C is the authority in the national Medicare laws that permit private companies to offer health insurance plans. They must meet or exceed Medicare Parts A and B.

The Medicare laws require private plans offer the benefits of the original federally operated coverage for hospital care in Medicare Part A and medical insurance in Medicare Part B.

These private sector plans known as Medicare Advantage Plans bring innovation and features with customer appeal. They operate through PPO and HMO organization structures as well as other healthcare services provider forms.

How does a Medicare Advantage plan work?

AdobeStock_28874646-1600x1600Federal Medicare administration approves companies and gives permission to offer Medicare Advantage plans. Medicare Advantage Plans must meet the standards of the original Medicare A and B for coverage.

They may offer attractive choices of care providers, advanced facilities, and additional benefits or coverages that contain consumer advantages. Medicare Advantage Plans usually offer drug costs protection found in Medicare Part D.

Medicare rules do not allow coverage for drug plans from two sources; one must get it from a Medicare Advantage program or a prescription drug Part D plan.

MA plans operate through business structures, and most are HMO or PPO organizations. The organizations set rules on the use of resources such as out-of-pocket costs, referrals, and co-pay rates for out of network services.

Why should you enroll in a Medicare Advantage plan?

The private companies that develop Medicare Advantage Plans can offer different styles of management, a wider array of choices, and means for customization of the plans.

They can extend the range of doctors, facilities, and permit optimization of plan benefits — including savings accounts that use cash advances to cover medical costs.

Overall, Medicare Advantage Plans provide choices that are not always available through original Medicare. For a given family or individual situation, there may be far more useful resources and price savings in a Medicare Advantage Plan than in other options.

What are the different types of Medicare Part C plans?

AdobeStock_67096488-1600x1600The plans differ by price and service features as well as by their purposes. The types are HMO Plans, Preferred Provider Organization Plans, Private fee -for- service (PFFS) Plans, Special Needs Plans, HMOPOS plans, and Medical Savings Account Plans. Some serve a narrow group with a wide array of services aimed at the needs of that group.

The Special Needs Plan is an example. They often focus on needs of those with a common disease, such as HIV and AIDS, and mode of treatment such as long-term care. They add specialists and medical resources that the group can share.

– HMO

Most HMO providers follow a model requiring a primary care physician as a gateway to a client’s medical services. This person helps assign resources to patients. This mode usually restricts the patient to network resources for treatment except in emergencies.

The HMO Point of Sale model is one variation on the no out of network services policy. This innovative approach permits a limited number of out of network services, but they usually come at a significantly higher price.

When choosing HMO plans, one should consider these things:

  • Plans usually include prescriptions in the coverage;
  • Patients get notices when a preferred or primary care doctor leaves the service, one may choose another doctor;
  • Care obtained outside the network may cost the client the full costs of those services.

– PPO

Preferred Provider Organizations are another very common structure for Medicare Advantage plan providers. The PPO differs from the HMO; the PPO allows the use of out of network resources. The customer pays more for out of network services than for in-network services.

Unlike the HMO model, there is no primary care physician and no requirement for referrals to see specialists. Flexibility in service providers comes with a relatively higher cost when choosing non-network resources. Prescription drugs are usually covered.

– PFFS

The original Medicare used an assignment agreement to control costs. The federal government set a price for each service and then set coverage at a maximum percentage of that cost determination. The doctor or provider accepting the assignment forgave the balance of the unpaid fees.

The private fee or service plan uses a similar approach. It sets the price for the service which can be accepted by any Medicare provider. This approach offers flexibility when selecting a service provider, and it tends to reduce or control prices for coverage.

– SNP

The Special Needs Plans are a category of Medicare Advantage plans that limit membership to people with particular disabilities or diseases. The limitation increases the efficiency of the plan for its members.

The members share the focused efforts to deliver and coordinate healthcare services. The plan can tailor efforts and benefits, including provider choices and drug formularies.

In these ways, the SNP serves the group far better than a broader array of services and providers. Patients must use services inside of the SNP network except for emergencies.

The SNP offers the advantage of specialists in the needed fields. A Special Needs Plan must be exclusive. It must limit membership to people with some important vital situation.

The limiting factors include the below-listed items:

  • People living in a particular institution;
  • People requiring nursing care at home;
  • Persons eligible for Medicaid in addition to Medicare;
  • People with chronic diseases and significant disabilities, conditions (like dementia, heart failure, kidney failure, severe diabetes, and HIV or full-blown AIDS).

SNP’s promote efficiency and high levels of service to members as follows:

  • Plans may further limit eligibility by adding other factors. Eligible participants can join an SNP at any time.
  • SNP’s are ideal for reinforcing care by coordinating services and healthcare providers to ensure high levels and responsive care. They can make it easy and convenient to follow doctor’s orders. Plans should coordinate the services and providers members need to help them stay healthy and follow doctor’s or other healthcare provider’s orders.
  • The SNP should determine that all of the healthcare providers in the network accept Medicaid as well as Medicare for payment. With Medicaid as well as Medicare, one can have the best chance of affordable quality care.
  • Patients that live in an institution such as a nursing home, hospital or extended care facility should determine that the SNP will serve the location. Many SNP’s have limited services areas.

– HMO POS

The HMO variation that permits outside service arrangements is the Point of Service option.

Essentially the HMO POS uses higher coinsurance or copayments to provide additional services and to allocate them on the basis of a price premium.

In a given locality, this may be an excellent way to use the services of an HMO and add out of network services as needed.

– MSA

Medical Savings Account plans offer flexibility and owner control over spending. They do not offer drug coverage so applicants will need to purchase a Prescription Drug Plan.

The structure of the MSA is a health plan with a high deductible. Medicare deposits funds in the account, and generally, an amount less than the deductible. The insured use the funds to pay for medical costs.

What are the eligibility requirements for Medicare Part C?

Medicare Advantage organizations are usually an HMO, PPO, Private Fee for Service (PFFS) organization, or Medicare Medical Savings Account Plan. You are eligible to join a Medicare Advantage Plan when you meet the three criteria listed below.

  • The MA Plan must serve the area of the applicant’s primary residence.
  • Applicants must have an active account in Medicare Part A and Part B
  • Applicants may not have a confirmed diagnosis of End Stage Renal Disease

When can you enroll in a Medicare Advantage Plan?

mda-604x362-5Applicants can enroll in Medicare Advantage during Initial Enrollment periods and Special Enrollment periods. Some Medicare Advantage groups have unlimited enrollment availability such as Special Needs Groups.

The rules provide for particular periods to signup for a Part C Medicare Advantage Plan. The windows open and close on specific dates.

It is during these designated time periods when applicants can get a Medicare Advantage Plan, a Prescription Drug Plan, or to make changes to coverage already in existence.

Applicants can sign up for a Medicare Advantage Plan (like an HMO or PPO, Medicare prescription drug coverage) or make changes to coverage already in place during the Initial Enrollment Period.

The Initial Enrollment Period is the occasion of Medicare eligibility. For most applicants, it is the 65th birthday. Applicants can make these changes and additions during designated enrollment periods that happen each year.

The Medicare Open Enrollment Period runs from October 15 to December 7 each calendar year and permits these changes:

  • Switches to or from original Medicare to Medicare Advantage.
  • Switches between Advantage Plans including those that do not offer prescription coverage.
  • Add Prescription Plan coverage, drop coverage, or switch to a new prescription plan.

– Medicare Advantage Dis-enrollment Period

This special period runs from January 1 to February 14 each calendar year. It provides a designated period to disenroll from Medicare Advantage and return to the original Medicare. There are limits to the changes that can be made, and they are stated more particularly below.

– Using the Medicare Advantage Dis-enrollment Period

Medicare Advantage Disenrollment Period runs from January 1 to February 14 of each calendar year. Consumers can use the Medicare Disenrollment period to make a wide range of changes and select options.

Applicants can leave a Medicare Advantage plan and return to Medicare. They can take up to February 14 to add a Prescription Drug Plan. Coverage begins the first day of the month after the changes.

There are changes not permitted during the dis-enrollment period as follows in the below-itemized list:

  • No Switch from Original Medicare to a Medicare Advantage Plan
  • No Switch from one Medicare Advantage Plan to another
  • No Switch from one Medicare Prescription Drug Plan to another
  • Cannot join, switch, or drop a Medicare Medical Savings Account (MSA) Plan

– Initial Coverage Election Period

The initial election period varies by age and condition. The usual Initial Election Period occurs around the 65th birthday month. It is the seven-month period around the 65th birthday month. Those reaching age 65 can sign up for Medicare Advantage three months before and three months after the 65th birthday month.

Those who sign for Medicare Advantage have the option of canceling and reverting to Medicare during the 12 months after signup.

The below-listed items are options during the Initial Election Period:

  • People who turn 65 can apply for Medicare Advantage during their Initial Enrollment Period. The Initial Enrollment Period is a  seven-month process and runs from three months before the birth month through three months after the birth month.
  • Disabled eligible under 65 can sign up for Medicare Advantage Plans
  • Disabled eligibles that turn 65 can use an Initial Enrollment Period to sign up for Medicare Plans
  • Applicants with Medicare A adding B during General Enrollment January 1 through March 31 can add Medicare Advantage within the following calendar period of April 1 to June 30.

– Annual Election Period

The Medicare Open Enrollment Period runs from October 15 through December 7:

  • Permits changes to or from original Medicare to Medicare Advantage
  • Switch between Advantage Plans including those that do not offer prescription coverage
  • Add Prescription Plan coverage, drop coverage, or switch to a new prescription plan

– Special Election Period

Life conditions create Special Enrollment Periods (SEP) for Medicare Advantage Plans. Under certain circumstances, events or changes qualify for a Special Enrollment Period, which includes simple things like a change of address or location.

The below-listed items are examples of SEP changes:

  • When moving the household, you have the opportunity for new coverage because providers determine price and benefits by location.
  • You obtain eligibility for Medicaid, which causes a wide range of insurers to be available.
  • When you qualify for the program assistance of Extra Help with Medicare prescription drug costs, you can use an expanded set of plans.
  • A change of treatment circumstances causes new coverage options, such as when the applicant receives care in a healthcare institution, a skilled nursing facility, or a long-term care hospital.

How much will Medicare Part C cost?

The costs of Medicare Part C depend upon the private companies that offer plans. They decide each year the annual amounts they will charge for monthly premiums, deductibles, and individual copayments and co-insurance.

The other area of costs is out of pocket costs which, in addition to deductibles, include costs for services outside of plan coverage.

References:
  1. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/medicare-advantage-plans.html, “Medicare Advantage Plans,” Jul 1, 2016.
  2. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/how-medicare-advantage-plans-work.html, “How do Medicare Advantage Plans work?,” Jul 1, 2016.
  3. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/types-of-medicare-advantage-plans.html, “Different types of Medicare Advantage Plans,” Jul 1, 2016.
  4. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/hmo-plans.html, “Health Maintenance Organization (HMO) Plan,” Jul 1, 2016.
  5. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/preferred-provider-organization-plans.html, “Preferred Provider Organization (PPO) Plans,” Jul 1, 2016.
  6. https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/original-medicare/how-original-medicare-works.html, “How Original Medicare works,” Mar 15, 2018.
  7. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/private-fee-for-service-plans.html, “Private Fee-for-Service (PFFS) Plans,” Jul 1, 2016.
  8. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/special-needs-plans.html, “Medicare Special Needs Plans (SNP),” Jul 1, 2016.
  9. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/types-of-medicare-advantage-plans.html, “Different types of Medicare Advantage Plans,” Jul 1, 2016.
  10. https://www.medicare.gov/Pubs/pdf/11206.pdf, “Your Guide to Medicare Medical
    Savings Account (MSA) Plans,” Jul 1, 2016.
  11. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/who-can-join-medicare-advantage-plan.html, “Who can join a Medicare Advantage Plan?,” Jul 1, 2016.
  12. https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/how-to-join-a-medicare-advantage-plan.html, “How to join a Medicare Advantage Plan,” Mar 15, 2018.
  13. https://www.cms.gov/Outreach-and-Education/Reach-Out/Find-tools-to-help-you-help-others/Medicare-Open-Enrollment.html, “Medicare Open Enrollment,” Mar 15, 2018.
  14. https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/when-can-i-join-a-health-or-drug-plan.html#collapse-3190, “Joining a health or drug plan,” Jul 1, 2016.
  15. https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/special-circumstances/join-plan-special-circumstances.html, “Special circumstances (Special Enrollment Periods),” Jul 1, 2016.
  16. https://www.medicare.gov/your-medicare-costs/medicare-health-plan-costs/costs-for-medicare-advantage-plans.html, “Costs for Medicare Advantage Plans,” Jul 1, 2016.

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MULTIPLAN_GHHK5LLEN_Accepted Last Updated 3/18/2018