Part C = Medicare Advantage

A Medicare Advantage plan is a private plan you may join as an alternative way to get your Part A and B benefits. When you do, Medicare pays the plan a fee every month to administer your Part A and B benefits. You must stay enrolled in Medicare Part A and B while enrolled in your Medicare Advantage plan. Medicare pays the Advantage plan company on your behalf to take on your medical risk. This is how Medicare Advantage plans are funded.

You will present your Advantage plan ID card at the time of treatment. Your providers will bill the plan instead of Original Medicare. Again, this is also why some providers consider them Medicare replacement plans.  Still, it's important to remember that you can always return to Original Medicare during a future annual election period.

Each Advantage plan has its own summary of benefits.  This summary will tell you what your copays will be for various healthcare services.  Your plan will off all the same services as Original Medicare, such as doctor visits, surgeries, lab work and so on.  You might pay $10 to see a primary care doctor while specilist visit copays will often be more for example; $50. Some of the high copays you'll be responsible for may come in for such things as: diagnostic testing, imaging, hospital stays, and surgeries.

These copays you can expect to be significant and in the hundreds of dollars and do vary state by state, carrier to carrier so its important to review plans available to you in your area and understand the specifics.

One very nice thing about Medicare Advantage plans is that they offer some additional benefits like routine dental, vision, hearing, gym memberships OTC cards etc.  When working with HSB we can compare these benefits between the various carrier plans in your area! 

You agree to play by certain rules in exchange for lower premiums that Advantage plans offer. Most Medicare Advantage plans are going to have either a HMO or PPO network.

HMO network= these are generally required to treat only with network providers, except in emergencies.  You will usually need to select a primary care physician- he or she with then coordinate a referral if you need to see a specialist.  Some HMO plans offer a point-of-service feature where you can see out-of-network in certain circumstances.  

PPO network= these will allow you to see doctors outside the network, but you'll normally have a higher out-of-pocket copay for these services.

If you're on the fence in deciding to go the Medigap or Medicare Advantage route you'll want to consider some of the rules prior to any enrollment.

1. You must be enrolled in Medicare Part A & B and live in the plan service area. Some people think if they drop Part B if they enroll in a Medicare Advantage plan- this is not the case.  If you drop Part B whil enrolled, you will immediately be disenrolled from your Medicare Advantage plan.
2. Use network doctors and hospitals for the lowest out-of-pocket costs.  Plans may have HMO or PPO networks.  Most HMO plans do not cover anything out of network except emergencies. With PPO network, seeing a provider/facility outside the network will result in higher spending.
3. Advantage plans may require Prior Authorizations for certain procedure's.
4. You may need to obtain a referral from your primary care doctor before seeing a specialist on most HMO style plans.

Put your Medicare card (the red, white and blue one) in a safe place.  Do not give it to any of your healthcare providers,  If they bill Medicare, those bills will be rejected because they should have been sent to your Medicare Advantage insurance company for processing.  You must direct your providers to bill your Medicare Advantage plan.  People who enroll in Advantage plans are agreeing, for the rest of the calendar year, to be covered by the plan instead of Original Medicare.

Advantage plans have what are called: Lock-in Periods.  You can enroll in one during the Initial Enrollment Period when you first turn 65.  After that, you may enroll or dis-enroll only during certain times of the year.  Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year. You may dis-enroll from an Advantage plan during certain times of the year unless you qualify for a special enrollment period due to specific circumstances. 

Annual Election Period- this is the most common time to change your Medicare Advantage plan.  This period runs October 15 - December 7 each fall.  Changes to your enrollment will take effect on January 1.

If you leave an Advantage plan and return to Original Medicare you must notify your Medicare Advantage plan carrier.  Otherwise, Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare.

Open Enrollment Period- runs from January 1 - March 31 each year.  This is the timeframe available for you to change from your current  Medicare Advantage plan to a different Medicare Advantage plan.  This change is only allowed once per calendar year.  During this timeframe you can also disenroll from any Medicare Advantage plan and return to Original Medicare.  Additionally, if needed you will be allowed to add a standalone Part D drug plan.

Open Enrollment Period does not mean you can return to a Medigap plan you had before.  Unless this was your first time in a Medicare Advantage plan, you will usually have to answer health questions and undergo medical underwriting to get re-approved for Medigap.  Consider this before dropping any Medigap plan to go to Medicare Advantage.

In 1997 when Medicare Advantage plans were created the intent by Congress was to give you options for accessing your Medicare benefits. Some reasons why people choose an Advantage plan:

• Many plans have low monthly premiums- some even $0 per month. (you must continue to pay your Medicare Part B premium)
• You pay for medical services as you use them in the form of copays and coinsurance.
• Unlike Original Medicare, Medicare Advantage plans have an out-of-pocket maximum cap to protect you against catastrophic spending.
• The convenience of having your medical and Part D drug benefits rolled into one plan.
• Some plans may include benefits for things like vision, hearing, dental, OTC, gym etc..

Remember= It's a personal choice - there is no right or wrong.  Consider Original Medicare vs Medicare Advantage based on your own knowledge of your medical use.

Looking for comprehensive coverage?  There is no doubt Medigap plans will get the job done.

Knowing the primary difference- you can see any doctor that accepts Medicare with Medicap plans.  You don't have to ask your doctors if they take your specific Medicap insurance company as the network is Medicare, which has over 1 million contracted providers across the country.

Some Medigap plans also have fuller coverage on the back end.  Medicare pays 80%, and your Medigap plan can pay some or all of the other 20%, depending on which Medigap plan you choose.  This leaves you with little out-of-pocket.  For example, a beneficiary with a Medigap plan G won't have the repetitive copays at the doctor that they might incur on a Medicare Advantage plan.

However, Medigap plans do not include Part D coverage, so you will need to buy a seperate Part D policy.  They also do not offer routine dental, vision, hearing and other additional supplemental benefits that most Medicare Advantage plans come with.

Remember= Again, there is no right or wrong.  These two types of coverage just work differently.  Go with the option that feels right for you.