Medicare Advantage

Your Ultimate Guide to Medicare Part C

As we age, our healthcare needs change, and it becomes important to have a reliable healthcare plan in place. If you’re on Medicare, you have the option to enroll in a Medicare Advantage Plan. But what exactly is Medicare Advantage Plan and how does it differ from traditional Medicare? 

This guide will help you understand the key features, benefits, and drawbacks of Medicare Advantage Plan and assist you in making an informed decision

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Medicare Advantage Plans in Oregon

Medicare Advantage Plans offer a few additional benefits. Plans must provide the same quality of care as Original Medicare.

In 2023:

  • In 2023 there are 124 Medicare Advantage plans available to residents of Oregon, compared to 132 in 2022, for a decrease of 6.1%.
  • 100% of Oregon residents live in a county where premium plans at no cost to you are offered.

What is Medicare Advantage Plan?

Medicare Advantage Plan, also known as Medicare Part C, is a type of Medicare health insurance plan offered by private insurance companies. It provides all the benefits of Original Medicare (Parts A and B) and may include additional benefits.

What does Medicare Part C cover?

These health plans cover all the benefits of Medicare Part A, including hospital stays, skilled nursing care and home health care, but not hospice care (which is still covered by your Part A benefit). These plans also cover all the benefits of Medicare Part B, including doctor visits, outpatient care, screenings, shots and lab tests.

Many Medicare Advantage Plans also include Medicare Part D prescription drug coverage. Medicare Advantage plans work similarly to employer-sponsored health insurance plans that you may have had or currently have, which may help you continue a similar level of coverage to what you have now.

And also…

Medicare Advantage Plans

How does Medicare Part C works?

Medicare Advantage plans, also known as Part C, are offered by private insurance companies that have been approved by Medicare.

These plans provide all the benefits of Original Medicare (Part A and Part B) such as hospitalization and doctor’s visits. In addition, they typically include Medicare Part D prescription drug coverage and may offer additional benefits not covered under Original Medicare.

This can provide additional savings on these services. The plan’s network, costs, and rules may differ from Original Medicare, so it’s important to compare and review the plan before enrolling.

Medicare Advantage Plan Types:

HMO Plans-Health Maintenance Organization

  • Typically requires you to receive services from a network of local providers; except for emergency room, urgent care visits and renal dialysis services.
  • Often require referrals to specialists, depending on the plan.
  • Out-of-pocket costs are typically lower than PPO and POS plans.

POS Plans-Point-of-Service

  • Similar to an HMO plan, but you can also see providers for certain services outside the provider network; generally, at a higher cost.
  • Referrals to specialists may be required, depending on the plan.
  • Out-of-pocket costs are typically higher than HMO plans, but lower than PPO plans.

PPO Plans-Preferred Provider Organization

  • You can see providers for all covered services outside the provider network, generally at a higher cost.
  • Don’t require referrals to specialists.
  • Out-of-pocket costs are typically higher than HMO and POS plans

 Why Do People Choose Medicare Advantage? 

This type of Medicare plan is normally at low cost and may offer more benefits and lower out of pocket expenses than what Original Medicare covers such as the following: 

  • All Medicare Part A benefits
  • All Medicare Part B benefits
  • Most offer prescription drug coverage 
  • Mos may offer additional benefits not covered by Part A and Part B of Medicare
  • Planning alternatives with and without networks of providers
  • Limitations to yearly out-of-pocket costs for Medicare-covered services
  • Premiums to fit a variety of budget

How much does Medicare Advantage (Part C) cost?

In 2022, the average monthly Medicare Advantage premiums will vary for Medicare Part B and  for an Advantage plan depending on your income.

However, some Advantage plan premiums are no additional cost, while others are significantly higher than the national average. Depending on the level of coverage desired, a person can choose between low, medium, or high premium plans. 

Calculating the costs

Medicare Advantage plans have deductibles and cost-sharing in the form of copayments or coinsurance and monthly premiums. 

Both the state and the plan determine the amount of the above payments. The following factors also influence costs: 

  • the range and frequency of healthcare treatments required by an individual 
  • whether a person’s plan includes additional perks that come with greater rates 
  • whether a person visits a Medicare-accepting healthcare provider 
  • whether a patient seeks care from an in-network or out-of-network provider 

Coverage, copayments, and deductibles are all detailed in each plan.

Average Maximum Out Of Pocket

Providers of Medicare Advantage Plans set a yearly cost cap, which means that a person is not responsible for any spending that exceeds the maximum out of pocket. Unlike Original Medicare, there’s no cap. Which means, you can be exposed to an unlimited amount of expenses for any catastrophic medical event. 

Prescription drug portion of these plans have a different coverage gap and catastrophic coverage. Click here for more information

This is, however, the upper limit; many plans have lower caps.

Extra Help for Medicare Part C

Medicare premiums, including Medicare Advantage premiums, are not affordable for everyone. 

If you qualify for Medicare Savings Programs (MSPs) or Medicaid, you may be eligible for financial assistance on Part B premium and deductibles, copays, and coinsurance. Call us and see if you qualify for it. 

Original Medicare vs Medicare Advantage?

Original Medicare (Parts A and B) and Medicare Advantage (Part C) are two types of Medicare coverage. Both choices offer the same primary hospital and medical insurance coverage, but they have significant differences. 

Therefore, Original Medicare covers Part A ( includes inpatient hospital and skilled nursing services ) and Part B (covers doctor visits, outpatient services, and certain preventative care.)

All of the aforementioned (Parts A and B) are covered by Medicare Advantage plans, and most of them also include prescription medicines (Part D). Furthermore, while supplemental benefits differ by plan and provider, they may include additional benefits.

Medicare Advantage vs Medigap

Medicare Advantage plans are sometimes mistaken with Medicare Supplement Insurance. Private insurance firms offer both, but the method your expenses are covered differs. As the name implies, Medigap plans fill in the “gaps” in Original Medicare by covering your Part A and B deductibles and your co-insurance (usually 20%) of covered medical expenses. Your Medigap coverage will cover most of your copayments when you seek medical treatment. You’ll have to pay a monthly premium for this. Medicare Supplement Plan G is the most popular plan and it’s the most expensive because it offers the most coverage except the Part B deductible. 

On the other hand, Medicare Advantage plans are bundled plans that contain the same coverage as Medicare Parts A and B (and, in most cases, Part D) and limited coverage for items like vision, hearing, dental treatments and over-the-counter items. A Medicare Advantage plan may include a premium. However, many are offered at no cost over and above your mandatory Medicare Part B premium. When you go to the doctor or use any covered medical services, you’ll have to pay copays or coinsurance. The maximum out-of-cost limit in 2022 is $7,550.

How to choose the right Medicare Advantage plan for you?

When comparing Medicare Advantage plans, think about your health care needs and what each type of plan offers. If you have a chronic illness and want to stay seeing the same doctor or facility, you’ll need a plan that they accept. Some plans may have lower out-of-pocket payments than others if you take prescription medicines. 

Here are a few factors to consider while comparing Medicare Advantage plans: 

  1. The benefits 

Medicare Advantage Plans may offer additional benefits.

  1. The Cost

When looking for the best Medicare Advantage plan, one of the most crucial factors is the cost. You may want to take a look at the following:

  • monthly premium
  • Part B premium
  • in-network yearly deductible
  • drug deductible
  • in- and out-of-network out-of-pocket max
  • copays and coinsurance
  1. CMS Star Ratings

The CMS has created a 5-star rating system to assess the quality of Medicare Advantage and Medicare Part D (prescription medication) plans’ health and drug services. The CMS makes these star ratings and associated data public every year. 

When looking for the best Medicare Advantage plan in your state, the CMS ratings can be an excellent place to start. Consider investigating these plans to learn more about what is covered and how much they cost.

  1. In-Network Provider

Examine whether the plans you’re considering need you to join a provider network. If that’s the case, check if your doctors are part of that network. You can either consult your doctor or call the insurance company.

Medicare Advantage Plan Enrollment Periods

It is best to always review your plan, even if you are satisfied with your current health plan coverage. Every year Advantage Plans renew and may change thus it’s good to check if your deductibles, co-pays or co-insurances and benefits will be changing. You can do this by checking online, or calling your health plan advisor or representative. You may also opt to call your preferred provider to get to know more about the Medicare advantage plan or visit the nearest Social Security Office to find out more.

Here are the best times to enroll for a Medicare Advantage Plan:

Initial Enrollment Period
You can enroll 3 months before you turn 65, during your 65th birthday  or 3 months after you turned 65.

Annual Enrollment Enrollment Period

This runs from October 15 to December 7. Any plan signed during this enrollment period will take effect January 1st.

Open Enrollment Period
This enrollment period runs from January 1 to MArch 31 . During this period, you can switch Medicare Advantage plans, sign up for Medicare Prescription plan (Medicare PArt D) or may have options to remove it.

Special Enrollment Period
This enrollment period lets you make changes on your plan  depending on your qualifying circumstance such loss of group insurance, loss or qualify for Medicaid or Extra Help, full dual eligible, and recently move to a new area. 

>>>Learn More about Medicare Enrollment Periods

Medicare Advantage Plan Rules

Before getting signed up for a Medicare Advantage plan, it is good to keep the following in mind as Medicare Advantage plan can charge different co-pays or co-insurance:

  • Need for a referral to see a specialist
  • If you need to go to doctors, facilities  or providers that are under a plan for non- urgent/ non- emergency care.

It is important to note that these rules change every year, so it is best to always ask your provider or your insurance representative for any changes.

Medicare Advantage plan and Prescription Drug Coverage

Most Medicare Advantage Plans (Part C)  have Prescription Drug Coverage or Medicare Part D. However, you may opt to sign up for a separate Medicare PArt D plan if the plan doesn’t offer drug coverage (ex: Medical Savings Account plans) or the plan you choose does not offer a prescription drug coverage such as  Private fee- for Service plans. 

Medicare Part C Eligilibity:

To enroll in a Medicare Advantage plan, certain requirements must be met. These include:
  • being eligible for Medicare,
  • having an active enrollment in both Medicare Part A and Part B,
  • residing within the plan’s service area
  • Starting from 2021, individuals covered by Medicare with End-Stage Renal Disease (ESRD) can now sign up for any Medicare Advantage (MA) plan.

It is important to check your Medicare card to confirm your current enrollment status in Part A and B. It is also important to note that the coverage area of the plan is based on the county of residence and not the state of residence.

Frequently asked questions

Who is eligible to enroll in a Medicare Advantage Plan? 

Those who have Medicare Parts A and B are eligible. People with ESRD can choose either Original Medicare or a Medicare Advantage Plan for their Medicare coverage.

Does Medicare Advantage plan offer prescription drug coverage?

Prescription drug coverage is available in most (but not all) Medicare Advantage plans. If you want prescription drug coverage, make sure it’s covered in the plan you’re considering before enrolling.

Do all doctors accept Medicare Advantage?

Not all doctors accept Medicare Advantage. In most cases, you must seek medical care from physicians in your Medicare Advantage plan’s network. Some plans only enable you to use out-of-network providers in an emergency; others allow you to use them whenever you want but at a higher out-of-pocket expense.

Does Medicare Advantage cover travel? 

Most Medicare Advantage plans cover emergencies up to a certain amount at a time. 

Does Medicare Advantage work with Medicaid or Oregon Health Plan? 

Yes, Medicare Advantage is the primary insurance and Oregon Health Plan becomes the secondary which pays for any deductibles, co-pays or co-insurance after Medicare Advantage pays. 

Can I enroll on Medicare Advantage along with my VA benefits? 

Yes, as long as you have Medicare Part B. 

Does Medicare Advantage Plan automatically renew?
Yes, unless Medicare cancels its contract with your current plan or your insurance provider decides not to offer the plan you are currently enrolled in.

Can I add a Medicare Advantage Plan anytime?
No. You can only add or change plans during given enrollment periods.

Am I allowed to switch back  from Medicare Advantage plan to my Original Medicare?
Yes. You can switch back to original Medicare at any point during your first year in Medicare Advantage plan or any qualified enrollment period. Read more here for Medicare Special Election Period

Does the Medicare Advantage Plan have a limit out of pocket maximum?
Yes. All Medicare Advantage Plans have out-of-pocket or deductible maximum.

Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.

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