What is Medicare Advantage?
Medicare Advantage plans (also known as Part C) are all-in-one of Medicare health insurance programs. Instead of the Feds administering your Medicare directly, they hand over the Part A and B premiums to private insurance companies, which can be more efficient with the money and offer benefits that Original Medicare doesn’t offer. These companies have to offer the same exact coverage that Original Medicare does, such as colonoscopies or flu shots, and follow rules set by Medicare.
Medicare Advantage-Prescription Drug (MAPD) plans combine Part A, Part B, and Part D through HMO or PPO plans. Besides this, they often can offer benefits that Original Medicare doesn’t give, depending on the company and your area. I like to say that “Original Medicare only covers you from the neck down! You have to take care of the outside of your head yourself.” In the Southern California market, one company will send helpers over to lend a hand around the house, another will take your dog for a walk when you’re in the hospital, and others will give you “Flex” Cards toward various benefits. The choice is yours!
What’s cool about MAPD plans is, that in many areas, the premiums are zero premium, so you only pay for your Part B premium. Some companies even rebate money to your Medicare Part B premium! MAPD plans also have a yearly Maximum out of Pocket (MooP), so once you’ve hit that spending limit, you’re done paying for the year.
Generally, most MAPD plans will include the Part A, Part B, and Part D deductibles, and there are often no to low copayments for visits with your primary care physician.
MA Plans (Medicare Advantage only, no Prescription Drug Benefit)
For Veterans and others with creditable drug coverage, there are also MA-only plans. These can be a boon to veterans if they receive their medical care and prescription drugs from the Veterans Administration medical service. Why? Because while they keep their VA medical benefits, they can also add in hearing aids, dental care, eyeglasses, acupuncture, chiropractic, etc. Various plans in Southern California also offer to rebate money back every month to your Social Security check month in 2024!
A Little Health Insurance Lingo Here
When you compare health insurance plans, take into account the following features from the Summary of Benefits:
Premium: Your monthly cost to be enrolled in the plan.
Deductible: The amount you pay before the insurance company pays their part for a service, such as a hospital visit.
Copayment: The amount you pay to the doctor or physical therapist, etc. when seeking care. Most of your costs on a Medicare Advantage plan will be as copayments.
Coinsurance: A percentage you pay with the health plan for a covered service. You may have a coinsurance to buy durable medical equipment (DME) like canes or walkers. You pay a percentage of the total cost for that equipment instead of a copay.
Maximum out of Pocket (The MooP): This is the most you would pay for covered services in a calendar year. After you spend this dollar amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits for the rest of that calendar year.
The MooP is one of the biggest advantages of Medicare Advantage compared to only using your Original Medicare. Medicare Advantage plans set a limit to what you’ll spend out of your own pocket on healthcare every calendar year. For example: If you are incredibly ill one year and hospitalized frequently or have a catastrophic accident, Original Medicare has no limit to protect what you’ll spend on your healthcare bills, so in theory you could easily be stuck with $100,000 in medical bills for that year. With Medicare Advantage however, in that same scenario, you only pay up to your plan’s maximum out of pocket.
Are you afraid of The MooP? Don’t be – in California less than 2% of people on Medicare Advantage plans ever get to their MooPs, and that number is less than 4% nationally.
In Network vs. Out of Network
When you are on Original Medicare, with or without a Medicare Supplement, you have no networks to worry about. You are as free as the rain, and like the rain, you can go wherever Medicare is accepted. When you are on a Medicare Advantage plan, you are confined to a network or medical group and must go through their channels for your medical care. Below are typical kinds of Medicare Advantage plans.
Health Maintenance Organization (HMO): You must see your primary care physician (PCP) from your medical group for treatment. Your PCP is responsible for submitting authorizations to see specialists, for example, an orthopedic surgeon or a physical therapist. If you have a problem getting an authorization, contact your medical group to appeal the decision.
HMO-POS: This is a hybrid kind of plan, which is an HMO with a Point of Service component. With a Point of Service option, you can see providers out of your medical group for the price of a (higher) copay. These plans generally do not have premiums, like a regular HMO, and allow you to get a second opinion outside of your network, like a PPO. So these are slightly more flexible than your regular HMO plan, and less costly than a PPO.
Preferred Provider Organization (PPO): You can go to any physician you like within your plan’s network (not medical group) and pay the lower cost. You can also go to any physician not in your network, but you pay more. There is more freedom with a PPO, but you pay for the privilege. If your PPO has a large network, then you have a lot of options for care! There are national PPOs, meaning you can go out of state and still be “in network.” 😊
What If It’s an Emergency?
Don’t worry, urgent care, emergency room visits, and renal dialysis are always considered in-network.
Kinds of Medicare Advantage Plans
HMO: Health Maintenance Organization with networks and Primary Care Physician directing your healthcare.
C-SNP: Chronic Special Needs Plans for people with chronic medical conditions like heart disease, diabetes, kidney disease, etc. There’s even one for mental illness in California! These plans are tailored toward the needs of these clients. For example, a diabetes C-SNP may include certain insulins at $0 copay, whereas the same company may offer a heart plan to a diabetic and the insulin would have a minimal copayment.
D-SNP: Dual-Eligible Special Needs Plans for people on Medicare and Medi-Cal (Medicaid for you non-Californians!). Some companies offer D-SNP plans for people with a share of cost. These plans offer very generous benefits to their clients, like additional funding for eyewear, dental coverage, hearing aids, and groceries. Some plans are even helping to pay for service animals!
I-SNP: Institutional Special Needs Plans, which are for people confined to nursing homes.
HMO-POS: HMO plan with a Point of Service component; you pay a copay to see a provider who’s not in your medical group
PPO: Preferred Provider Organization, where you can go to a provider in your Medicare company’s network or out of it, without a referral. You pay for this priviledge, but unlike a Medicare Supplement, you cannot be turned down from a PPO plan, regardless of any pre-existing conditions. Plus your drug coverage is usually included.
In an HMO? You Will Also Choose a Medical Group
Underneath your HMO health insurance plan is your medical group or Independent Physician Association (IPA). The Medicare Advantage insurance plan takes care of the money part and benefits, and the medical group provides the actual medical treatment.
Which medical group you choose makes a difference! Did you know that certain hospitals only take patients from specific medical groups for scheduled procedures? Example: If an ambulance takes you to Humungous Hospital in an emergency, you’ll be treated because it’s an emergency, but if you want a knee replacement at Humungous Hospital, you need to belong to one of their specifically contracted medical groups to be able to schedule your surgery there. Even if your health insurance plan is accepted by that hospital, if your medical group doesn’t have access, you don’t either. So both the insurance plan and medical group need to align to access the hospital of your choice. Conversely, if your medical group has a massive contract, it will cover you in a hospital where your insurance plan doesn’t go!
Various medical groups/IPAs can also offer some further help to their patients, like free transportation to doctor visits, expedited authorizations, and translation services. It’s worth investigating which medical group or groups your doctor is in network with and choose accordingly. This is where it’s helpful to have an agent (like me!) to help you, because I know which groups go to which hospitals!
Why Choose a Medicare Advantage Plan?
Are all your doctors in the same medical group? Do you need the additional benefits that Original Medicare doesn’t offer, like dental or transportation, or over-the-counter pharmacy items? Do you tend to stay in your area, or do you frequently travel the U.S.? Can you afford a Medicare Supplement or would you rather save the money (or even have money returned)? These are all questions to ask yourself while you’re thinking about Medicare. Do you have any questions you’d like to ask me? Please give me a call or fill out the form below to contact me. I’m happy to help.
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