Have you ever wondered how a Medicare Advantage Plan works? Medicare Advantage Plans are sometimes referred to as MA/ MAPD plans or Medicare Part C. These plans are approved by Medicare but are offered by private insurance companies. Here are a few things you will need to know:
If you join a Medicare Advantage Plan you still have Medicare, but you will get your Medicare Part A (hospital insurance) and your Medicare Part B (medical insurance) from your Medicare Advantage Plan and not from Original Medicare. Which means the plan will be billed directly for approved services instead of Medicare, except hospice. Medicare sets the rules for Medicare Advantage Plans and regulates the private companies who operate the plans.
Conditions to enrolling in a Medicare Advantage Plan
A person must meet some certain conditions to be eligible for a Medicare Advantage plan. If someone wishes to enroll in an MA / MAPD plan, they must:
- Be eligible for Medicare
- Must be enrolled in both Medicare Part A and Part B. This can checked this by looking the your Red, White and Blue Medicare card)
- They must live within the plan’s service area
- Cannot have End-Stage Renal Disease (ESRD)
Coverage and Cost
Medicare Advantage Plans cover all Medicare services. Part C plans have a yearly limit on out-of-pocket costs for medical services and once the limit is reached, you will pay nothing for the remainder of the year for covered services. Limits will vary by plan. Although all Medicare Advantage plans must cover medically necessary services, each plan will have different co-pays, deductibles, various co-insurance terms as well as added benefits. The additional benefits may include eye care, dental and even fitness programs, this will depend on the carrier and your service area. Each plan can have different rules for how you receive services such as whether you need a referral to see a specialist or if you have to utilize network doctors and hospitals that belong to the plan. These rules can change every year.
Prescription Drug Coverage
MAPD (Medicare Advantage Prescription Drug) plans offer Prescription Drug Coverage, vs an MA (Medicare Advantage) does not. MA plans are ideal for Veterans who will continue to receive their medications from the VA or a beneficiary who has a Creditable (as good as Medicare) Prescription plan. This will NOT include drug discount programs. On most cases, a beneficiary will NOT be able to join a Medicare Prescription Drug Plan in addition to their MA / MAPD plan. There are a few exceptions to the rule, for example, if you are enrolled in a PFFS plan or Medicare Cost Plan.
How do you choose an MA plan?
It is important to compare the benefits of plans you may be eligible for to make sure you are getting the plan that is right for your healthcare needs and your budget. Make sure that you understand all of the benefits the plan offers, and do not be afraid to ask questions, this is your health care at stake. In making this most important decision there will be several things you will want to consider such as:
- What are the costs associated with the plan? How much is the premium amount? Are there co-pays and coinsurance?
- Are your current doctors and specialists in your plan’s network?
- Does the plan have Prescription Drug Coverage? If so, are your medications on the plan’s formulary?
- Are there any additional services offered such as dental, vision or health club membership?
- If you are currently under treatment, does the plan cover it?
- Are there network restrictions?
