Medicare Advantage Plans are a popular option for many people who are eligible for Medicare, as they offer more benefits, lower costs, and better care coordination than Original Medicare. However, many people may not understand how Medicare Advantage Plans work, and how they differ from Original Medicare. In this blog post, we will explain what Medicare Advantage Plans are, how they pay instead of Medicare, and how to choose the best plan for your needs.
Original Medicare Plan
Original Medicare is the traditional way of getting Medicare coverage. It consists of two parts: Part A and Part B. Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care. Part B covers outpatient medical services, such as doctor visits, lab tests, preventive care, and durable medical equipment. Most people do not pay a premium for Part A, but they do pay a deductible and coinsurance for each service. Most people pay a monthly premium for Part B, as well as a deductible and coinsurance for each service.
Original Medicare does not cover everything. For example, it does not cover prescription drugs, vision, dental, hearing, or long-term care. To get prescription drug coverage, you need to enroll in a separate Part D Plan offered by a private company. To get additional coverage for the gaps in Original Medicare, you may also enroll in a supplemental insurance plan, also known as Medigap, offered by a private company.
Medicare Advantage Plans
Medicare Advantage Plans, also known as Part C or MA plans, are health insurance plans offered by private companies that contract with Medicare. They provide all the benefits of Original Medicare (Part A and Part B), plus additional benefits that Original Medicare does not cover, such as vision, dental, hearing, wellness, and prescription drug coverage. Some plans may also offer extra perks, such as gym memberships, transportation services, or over-the-counter items.
When you enroll in a Medicare Advantage Plan, you still have Medicare. However, you get your Medicare coverage through the plan instead of directly from the government. This means that the plan pays for your covered services instead of Medicare. You still have to pay your Part B premium to Medicare, plus any additional premium charged by the plan. You also have to follow the plan’s rules and regulations for getting care and services.
There are different types of Medicare Advantage Plans, such as:
Health Maintenance Organization (HMO) plans: These plans require you to use a network of providers and facilities that contract with the plan. You usually need a referral from your primary care provider to see a specialist. You may pay less out-of-pocket costs than other types of plans, but you may have less flexibility and choice in your care.
Preferred Provider Organization (PPO) plans: These plans allow you to use any provider or facility that accepts Medicare, but you may pay less if you use the plan’s network of preferred providers and facilities. You do not need a referral to see a specialist. You may pay more out-of-pocket costs than HMO plans, but you may have more flexibility and choice in your care.
Private Fee-for-Service (PFFS) plans: These plans let you use any provider or facility that agrees to the plan’s terms and conditions of payment. The plan decides how much it will pay for each service and how much you will pay. You do not need a referral to see a specialist. You may pay more or less out-of-pocket costs than other types of plans, depending on the plan’s payment rates and rules.
Special Needs Plans (SNP) plans: These plans are designed for people who have specific health conditions, such as diabetes, chronic heart failure, or end-stage renal disease; who are dual eligible for both Medicare and Medicaid; or who live in certain institutions, such as nursing homes. These plans provide tailored benefits and services to meet the special needs of these groups. You usually need to use the plan’s network of providers and facilities, and you may need a referral to see a specialist.
Difference Between Original Medicare and Medicare Advantage
Medicare Advantage Plans differ from Original Medicare in several ways. For example:
Coverage: Medicare Advantage Plans cover all the services that Original Medicare covers, except hospice care, which is still covered by Part A. However, Medicare Advantage Plans may cover some services that Original Medicare does not cover, such as vision, dental, hearing, wellness, and prescription drug coverage. Some plans may also cover extra perks, such as gym memberships, transportation services, or over-the-counter items.
Cost: Medicare Advantage Plans may have lower or higher costs than Original Medicare, depending on the plan’s premiums, deductibles, copayments, coinsurance, and out-of-pocket limits. You still have to pay your Part B premium to Medicare, plus any additional premium charged by the plan. Some plans may have zero or low premiums, but they may have higher deductibles or copayments. Some plans may have high premiums, but they may have lower deductibles or copayments. Some plans may also have an out-of-pocket limit, which is the maximum amount you have to pay for covered services in a year. Original Medicare does not have an out-of-pocket limit, which means you could pay unlimited costs for your care.
Benefits: Medicare Advantage Plans may offer more benefits than Original Medicare, such as vision, dental, hearing, wellness, and prescription drug coverage. Some plans may also offer extra perks, such as gym memberships, transportation services, or over-the-counter items. However, these benefits may vary by plan and may change from year to year. You should always check the plan’s benefit details before enrolling or renewing your plan.
Care coordination: Medicare Advantage Plans may offer better care coordination than Original Medicare, as they may have programs and incentives to help you manage your health and prevent complications. For example, some plans may assign you a care manager, who can help you coordinate your appointments, referrals, medications, and follow-ups. Some plans may also offer rewards or discounts for completing certain preventive or wellness activities, such as screenings, check-ups, or fitness classes.
Switching from Original Medicare to Medicare Advantage
If you are currently enrolled in Original Medicare, you may want to switch to a Medicare Advantage Plan for various reasons. For example, you may want to switch to a Medicare Advantage plan if:
You want more benefits and services than Original Medicare offers, such as vision, dental, hearing, wellness, and prescription drug coverage.
You want lower out-of-pocket costs than Original Medicare charges, such as deductibles, copayments, coinsurance, and out-of-pocket limits.
You want better care coordination than Original Medicare provides, such as care managers, programs, and incentives.
To switch from Original Medicare to a Medicare Advantage Plan, you need to enroll in the plan during certain times of the year. The most common time to enroll in a Medicare Advantage plan is during the Annual Enrollment Period (AEP), which runs from October 15 to December 7 every year. During this period, you can join, switch, or drop any Medicare Advantage plan. Your new coverage will start on January 1 of the following year.
Another time to enroll in a Medicare Advantage Plan is during the Open Enrollment Period (OEP), which runs from January 1 to March 31 every year. During this period, you can switch from one Medicare Advantage plan to another, or switch from a Medicare Advantage plan back to Original Medicare. Your new coverage will start on the first day of the month after you make the change.
You may also be able to enroll in a Medicare Advantage Plan at other times of the year if you qualify for a Special Enrollment Period (SEP). A SEP is a period of time when you can make changes to your Medicare coverage due to certain life events or circumstances, such as moving to a new area, losing your current coverage, becoming eligible for Medicaid, or having a chronic condition. The length and timing of a SEP vary depending on the situation.
Before switching from Original Medicare to a Medicare Advantage Plan, you should compare and evaluate different plans based on their coverage, cost, and benefits. You should also check their availability and eligibility requirements in your area. You can use [Medicare’s Plan Finder tool] or [Medicare’s Compare Plans tool] to help you with this process. You can also consult with a licensed insurance agent or broker, who can provide you with expert advice and support.
Medicare Advantage Plans Offered by Private Companies
Medicare Advantage Plans are offered by private companies that contract with Medicare. These companies are regulated by the government and must follow certain rules and standards. For example:
Coverage: Medicare Advantage Plans must cover all the services that Original Medicare covers, except hospice care, which is still covered by Part A. However, they can choose how to cover these services, such as what providers and facilities they use, what deductibles and copayments they charge, and what prior authorization or referral requirements they have. They can also choose to cover additional services that Original Medicare does not cover, such as vision, dental, hearing, wellness, and prescription drug coverage. Some plans may also cover extra perks, such as gym memberships, transportation services, or over-the-counter items.
Cost: Medicare Advantage Plans must offer at least the same level of coverage as Original Medicare for each service. However, they can charge different amounts for each service, such as premiums, deductibles, copayments, coinsurance, and out-of-pocket limits. They can also offer different levels of coverage for different types of services, such as in-network vs out-of-network services. They must notify you of any changes in their costs or benefits before the start of each year.
Conclusion
Medicare Advantage Plans are a great option for many people who want more benefits, lower costs, and better care coordination than Original Medicare. However, Medicare Advantage Plans are not the same as Original Medicare. They are offered by private companies that contract with Medicare, and they pay instead of Medicare for your covered services. This means that you have to follow the plan’s rules and regulations for getting care and services, and you may have different coverage, cost, and benefit options than Original Medicare.
We’re Here to Help
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FAQS
Does a Medicare Advantage Plan pay instead of Original Medicare?
Yes, a Medicare Advantage Plan (also known as Medicare Part C) is an alternative to Original Medicare (Part A and Part B) and provides the same coverage. Instead of having Original Medicare pay for your healthcare services, a Medicare Advantage plan pays for them on your behalf.
What are Medicare Advantage Plans?
Medicare Advantage Plans are private health insurance Plans offered by Medicare-approved companies. These plans combine the benefits of Original Medicare (Part A and Part B) and may also include additional benefits not covered by Original Medicare, such as prescription drug coverage (Part D), dental, vision, hearing, and fitness programs.
Can I still use Original Medicare if I have a Medicare Advantage Plan?
No, if you enroll in a Medicare Advantage Plan, you will generally receive all of your Medicare benefits through that plan. Most Medicare Advantage plans replace Original Medicare and become your primary insurance coverage.
What does a Medicare Advantage Plan cover?
Medicare Advantage Plans cover all the services covered by Original Medicare (Part A and Part B), including hospital stays, doctor visits, preventive care, and medically necessary services. Additionally, many Medicare Advantage Plans offer extra benefits like prescription drug coverage, dental, vision, and hearing care.
Are there different types of Medicare Advantage Plans?
Yes, there are several types of Medicare Advantage Plans, including Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO) plans, Private Fee-for-Service (PFFS) plans, and Special Needs Plans (SNPs). Each plan type has different rules and restrictions, so it's important to compare them to find the one that best meets your needs.
Can I switch from Original Medicare to a Medicare Advantage Plan?
Yes, during the Medicare Open Enrollment period (October 15 - December 7) each year, you can switch from Original Medicare to a Medicare Advantage Plan or vice versa. Outside of this period, you may have other opportunities to enroll in or switch Medicare Advantage Plans based on certain circumstances, such as moving to a new area or qualifying for a Special Enrollment Period.
Do I have to pay a premium for a Medicare Advantage Plan?
While Medicare Part A generally does not require a premium if you or your spouse have paid Medicare taxes for a sufficient amount of time, Medicare Part B does require a monthly premium. In addition to the Part B premium, some Medicare Advantage Plans may have their own additional premium, although there are also $0 premium plans available in some areas.
Can I have a Medicare Advantage Plan and a Medicare Supplement insurance policy at the same time?
No, you cannot have both a Medicare Advantage Plan and a Medicare Supplement (Medigap) insurance policy at the same time. Medicare Supplement Plans only work with Original Medicare, not Medicare Advantage. If you already have a Medicare Supplement policy and want to switch to a Medicare Advantage Plan, you should cancel your Medicare Supplement policy when your Medicare Advantage coverage begins.
Can I get prescription drug coverage with a Medicare Advantage Plan?
Yes, many Medicare Advantage Plans offer prescription drug coverage (Part D) as part of their benefits package. However, not all plans include Part D coverage, so if this is important to you, make sure to choose a plan that includes prescription drug coverage.
Are Medicare Advantage Plans only for low-income individuals?
No, Medicare Advantage Plans are available to all Medicare beneficiaries, regardless of income. However, there may be special Medicare Advantage Plans available for individuals who qualify for both Medicare and Medicaid (dual-eligible individuals) or have certain chronic conditions.
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