Medicare Advantage Plans Come In Different Sizes And Colors

Types Of Medicare Advantage Plans

MEDICARE ADVANTAGE PLANS

How much you pay for each visit or service (co-payment or coinsurance). For example, the plan may charge a copayment, such as $10 or $20, each time you see a doctor. These amounts may differ from those under Original Medicare. 

MEDICARE ADVANTAGE PLANS AND OPTIONS

MEDICARE HMO PLANS 

Medicare Advantage HMO Plans are the most popular type of Medicare Advantage Plans. These plans are a form of coordinated care in which you choose a primary care doctor from the network. You typically need a referral from that doctor before you can see a network specialist.

Medicare HMO plans often have the lowest monthly premiums of the three types of Medicare Advantage programs. This is because they are generally the most restrictive, requiring a primary care physician. Members visit their PCP first to obtain a referral before seeing a specialist.

MEDICARE PPO PPO PLANS

PPO Plans are also referred to as coordinated care plans. But PPO Plans are usually more flexible than Medicare HMO plans. Members can generally see any doctor in the network without a referral.  You can also use out-of-network providers, but you will pay more.

Always check the rules of your specific plan, which are available in the plan’s Summary of Benefits.

MEDICARE PFFS (PRIVATE FEE-FOR-SERVICE PLANS)

Private-Fee-For-Service Medicare Advantage Plans typically have no network or a very limited one. You can see any doctor who will bill the plan as long as they agree to the plan’s terms and conditions up front. This puts the burden on you to ask your providers whether they will accept the plan before you seek medical services. These plans have been phased out in many counties where at least two other plan types exist.

 

OTHER MEDICARE ADVANTAGE PLAN TYPES

Medicare Advantage (MA) and Medicare Advantage with Part D (MA/PD) plans vary by county. In fact, there are only a limited number of plans offered by each Insurance Company in each area where they participate. Across the country, there are many areas with few or no Medicare Advantage Plans available.

Special Needs Plans (SNPs) are available only to Medicare beneficiaries with certain health conditions. The plans are designed to address those health needs through specialized providers and drug formularies most suitable for people with those conditions. Most SNP plans are HMOs.

Medical Savings Account (MSA) plans provide a health savings account alongside insurance benefits. Medicare itself will put a set amount of funds into your account each year. You may spend those dollars whenever you access qualifying health services. MSA plans are not available in all counties.

NOTE: All Medicare Advantage plans offer their own summary of benefits. These benefits, as well as the plan’s formulary, pharmacy network, provider network, premium, and/or copayments/coinsurance, may change on January 1 of each year.

WHEN YOU CAN ENROLL IN A MEDICARE ADVANTAGE PLAN

You can join a Medicare Advantage plan during your 7-month Initial Election Period for Medicare. You can also join or disenroll from Medicare Advantage during the Annual Election Period. This occurs from October 15th to December 7th.

A variety of Special Election Periods exist, too. If you qualify, you might be able to join mid-year. A common one is when you move out of state and lose your existing Medicare Advantage plan. Medicare allows you a 63-day window to choose another plan in your new state. Another SEP occurs if you become eligible for Medicaid or the Part D Extra Help program. People with low incomes have continuous special election periods. This means you can change plans at any time of year.

YOU CAN CHOOSE ANY MEDICARE ADVANTAGE PLAN THAT IS AVAILABLE IN YOUR SERVICE AREA

Medicare Advantage programs have service areas. Service Areas are generally plans that are specific to the County you reside in. Remember that you must be enrolled in both Medicare Parts A and B and live in the plan’s service area. You cannot join a plan that does not operate in the county where you live. A licensed health insurance agent can help you determine which plan options exist in your county. They will help you work through a checklist of items to determine which plan best suits you.

HOW MUCH DO MEDICARE ADVANTAGE PLANS COST?

Your annual out-of-pocket costs in a Medicare Advantage or Medicare Part C Plan depend on:

• Some plans charge a monthly premium; others have no premium.

• Whether the plan pays any of your monthly Medicare Part B premium of $164.90 for the 2023 premium, some plans pay all or part of your Part B premium.

• Whether the plan has a yearly deductible or any additional deductibles.

• How much you pay for each visit or service (co-payment or coinsurance). For example, the plan may charge a copayment, such as $10 or $20, each time you see a doctor. These amounts may differ from those under Original Medicare. 

• The type of health care services you need and how often you get them.

• Whether you go to a doctor or a supplier who accepts assignment, if:

  • You're in a PPO, PFFS, or MSA plan.

  • You go out of your plan's network. 

• Whether you follow the plan's rules, such as using network providers.

• Whether you need extra benefits, and if the plan charges for them.

• The plan's yearly limit on your out-of-pocket costs for all medical services.

• Whether you have Medicaid or get help from your state.

Note: Each year, plans set the amounts they charge for premiums, deductibles, and services. The plan (rather than Medicare) decides how much you pay for the covered services you get. What you pay for the plan may change only once a year, on January 1st.

MEDICARE ADVANTAGE PLANS SEND INFORMATION TO THEIR MEMBERS EACH YEAR IN THE FALL

One of the most significant differences between Original Medicare and Medicare Advantage is that there are no guarantees that any Medicare Advantage plan will be available the following year. If it is, and you are comfortable with your plan and want to keep it (Again, as long as it is available) for the next year, you do not need to do anything; you will automatically be enrolled in the same Plan effective January 1st.

If you are not satisfied with your plan, you can choose a new one during the Fall Annual Enrollment Period (AEP). Once you enroll in a new MA or MA/PD plan, your current plan ends at midnight on December 31st, and your new plan begins at 12:01 AM on January 1st.

EVIDENCE OF COVERAGE (EOC)

The EOC provides details on what the plan covers, how much you pay, and more.

ANNUAL NOTICE OF CHANGE LETTER (ANOC)

The ANOC includes any changes to coverage, costs, or service area that will take effect in January.

SUMMARY OF BENEFITS (SOB)

Every Medicare Advantage plan includes a Summary of Benefits Section.  You need to read through this section and through the Explanation of Benefits section with a fine-toothed comb.  This is where you can see exactly how your benefits will be paid, and this is the fine print that the plan hopes that you will not read.

NOTE: If you don't receive these important documents, contact your plan.