What is Medicare Advantage?

Medicare Advantage, also known as Medicare Part C, refers to private insurance plans offered by insurance companies that combine the coverage of Original Medicare (Medicare Part A and Part B) with additional benefits. These plans typically provide a range of benefits, including hospitalization, select home healthcare services, hospice care, doctor visits, prescription drug coverage, preventive care, dental care, vision care, hearing care, and access to SilverSneakers fitness memberships.

Types of Medicare Advantage plans

Medicare Advantage plans come in various types to meet different healthcare needs. These include:

1. Health Maintenance Organization (HMO): HMO plans limit coverage to in-network healthcare providers and usually require referrals for specialist care.
2. Preferred Provider Organization (PPO): PPO plans offer coverage for both in-network and out-of-network providers, with varying costs depending on the provider used.
3. Private Fee-for-Service (PFFS): PFFS plans allow greater flexibility in choosing healthcare providers, but providers must agree to the plan’s payment terms in advance.
4. Special Needs Plans (SNPs): SNPs are designed for individuals with chronic health conditions and offer tailored benefits to meet their unique medical needs.
5. Medical Savings Account (MSA): MSA plans combine a high-deductible health plan with a medical savings account that can be used to pay for eligible healthcare expenses.

Medicare Advantage costs and coverage

When considering a Medicare Advantage Plan, it’s important to understand the potential cost-sharing involved. These plans can have different costs and rules compared to Original Medicare, so it’s essential to carefully review each plan before enrolling. Here are some of the key cost-sharing elements to keep in mind:

1. Medicare Part B Premium: In most cases, you’ll still need to pay the Part B premium for Medicare Advantage coverage. Some plans may also charge an additional premium, but in some cases, the plan may cover part of the Part B premium.
2. Deductibles: Medicare Advantage plans may have deductibles for various services, including inpatient, outpatient, and prescription drug coverage. Deductibles will vary depending on the specific plan.
3. Copayments: Medicare Advantage plans typically require copayments (a fixed amount you pay for each service) instead of the 20% coinsurance required by Original Medicare. It’s important to note that MA Plans cannot charge higher copays than Original Medicare for certain services, such as chemotherapy, dialysis, and skilled nursing facility care.
4. Maximum Out-of-Pocket Limit: All Medicare Advantage plans must have a maximum out-of-pocket limit, which caps the amount you pay out of pocket for covered services during a year. This limit includes deductibles and copayments, and it’s important to note that the limits can be high.

In addition to these cost-sharing factors, it’s important to understand the coverage rules for Medicare Advantage plans. Many plans will only cover services if you receive them from providers within the plan’s network. Before joining a plan, make sure your doctors and other providers are in the network and accepting new patients from the plan. It’s also important to note that providers may leave the plan at any time, and you can only leave the plan during certain enrollment periods without incurring a penalty.

Finally, while Medicare Advantage plans must cover the same services as Original Medicare, they may have different requirements or costs for certain services. For example, some plans may require your provider to get approval before providing certain services, or they may require referrals or prior authorization for certain types of care. Be sure to carefully review the plan’s details and rules before enrolling.

Maximum out-of-pocket limit

All Medicare Advantage Plans must establish an annual maximum out-of-pocket (MOOP) limit for your out-of-pocket costs. The MOOP limit is high, but it can prevent you from incurring excessive costs if you require a lot of care or expensive treatments. Once you reach your MOOP, you will not have to pay any more cost-sharing for covered services for the remainder of the year. Some plans may also apply the MOOP to supplementary benefits like dental, vision, or hearing.

The out-of-pocket costs that help you meet your MOOP include all cost-sharing, such as deductibles, coinsurance, and copayments, for Part A and Part B covered services you receive from in-network providers. However, cost-sharing for Part D does not apply to your plan’s MOOP.

The MOOP for Medicare Advantage Plans in 2023 is $8,300, but some plans may set lower limits. If you are enrolled in a plan that covers services received from out-of-network providers, such as a PPO, your plan will set two annual limits on your out-of-pocket costs: one for in-network costs and the other for combined in-network and out-of-network costs.

Medicare Advantage enrollment

To enroll in a Medicare Advantage Plan, there are specific periods throughout the year when you can do so. To join an MA Plan, you must be enrolled in Medicare Parts A and B. The following are the periods when you can typically enroll in Medicare Advantage:

• Initial Enrollment Period (IEP): This is a seven-month period that includes the three months before, the month of, and the three months after the month you become eligible for Medicare (either your 65th birth month or the 25th month you have collected disability benefits).
• Part B Special Enrollment Period (SEP) for losing job-based insurance: If you were covered by job-based insurance when you first became eligible for Medicare, this Part B SEP lets you delay enrollment in Part B without penalty. You can enroll in Medicare without penalty for up to eight months after you lose job-based coverage. You can then enroll in an MA Plan after signing up for Part A and B coverage.
• Part B SEPs for exceptional circumstances: There are SEPs for less common situations, such as if you live in an area impacted by a natural disaster or emergency situation. You can enroll in an MA Plan after signing up for Part A and B coverage.
• General Enrollment Period (GEP): This period occurs between January and March each year when you can sign up for Medicare if you didn’t initially enroll. Coverage begins the first of the month after the month you enroll. You can enroll in an MA Plan after signing up for Part A and B coverage. It’s advisable to sign up for a plan during the same month that you enroll for Parts A and B.
• Fall Open Enrollment Period: This period lasts from October 15 to December 7 each year when you can change your Medicare coverage. You can choose a new MA Plan, switch between Original Medicare and Medicare Advantage, or change your Part D coverage during this time.

Know more about the Medicare Enrollment Periods here

Factors to consider before joining a Medicare Advantage Plan

Before joining a Medicare Advantage Plan, it’s important to consider several factors to ensure that the plan meets your healthcare needs and budget. Some key factors to consider include:

1. Network: MA Plans may require you to use doctors, hospitals, and pharmacies that are in their network, so it’s important to check if your preferred healthcare providers are included in the plan’s network.
2. Benefits: MA Plans offer different benefits and may have different coverage rules for services like vision, dental, and hearing, so it’s important to carefully review each plan’s benefits and rules to ensure they meet your needs.
3. Cost: MA Plans may have different cost-sharing structures, such as deductibles, copays, and maximum out-of-pocket limits, so it’s important to compare the costs of different plans to find one that fits your budget.
4. Prescription drug coverage: If you take prescription medications, it’s important to check if the plan covers your medications and if there are any restrictions or requirements, such as prior authorization.
5. Provider referrals: Some MA Plans require you to get a referral from your primary care physician before seeing a specialist, so it’s important to understand the plan’s rules around referrals if you have complex medical needs.
6. Plan ratings: Medicare provides quality ratings for MA Plans based on factors like customer satisfaction and healthcare outcomes, so it’s important to review the plan’s ratings to get an idea of its overall performance.

By carefully considering these factors, you can make an informed decision about which Medicare Advantage Plan is the right fit for your healthcare needs and budget.

FAQS

Will my prescription drugs be covered under a Medicare Advantage Plan?

Most Medicare Advantage Plans include prescription drug coverage, but you should check with the plan to make sure the drugs you need are covered.

Are there any extra costs associated with Medicare Advantage Plans?

Yes, you may have to pay copayments, coinsurance, and deductibles for the services you receive under a Medicare Advantage Plan. You should also check if the plan has an annual out-of-pocket limit.

Can I switch from one Medicare Advantage Plan to another?

Yes, you can switch plans during the Annual Enrollment Period (AEP) or the Medicare Advantage Open Enrollment Period (OEP).

Conclusion:

A Medicare Advantage Plan can be a good option for those who want additional benefits beyond Original Medicare. However, before enrolling in a plan, you should consider the cost, benefits, and network of providers. You should also check if your medications are covered under the plan and if there are any extra costs. If you decide to enroll in a Medicare Advantage Plan, be sure to choose a plan that meets your healthcare needs and fits within your budget.

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