Can anyone join a Medicare Advantage Plan?
No. A person must meet a few conditions to eligible for a Medicare Advantage Plan. If you wish to enroll in a Medicare Advantage Plan (a MA or MA-PD), you must be:
For example, if you and a friend both have Medicare Part A and Part B, but live in different counties, your friend my be able to join a Medicare Advantage Plan that has a prescription drug benefit (MA-PD) with a $0 monthly premium. However, this same MA-PD may not be available in your county a few miles away.
- eligible for Medicare,
- enrolled in both Medicare Part A and Medicare Part B (you can check this by referring to your Red, White, and Blue Medicare Card),
- live within the Plan’s service area (which is county-by-county - not state-by-state), and
- not have End-Stage Renal Disease (ESRD). However the ESRD rule is changing. Beginning in 2021, you can join a Medicare Advantage plan (MA or MAPD) even If you have End-Stage Renal Disease.
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Do you lose your Original Medicare Part A and Part B when you enroll in Medicare Advantage Plan?
No. Once enrolled in a Medicare Advantage Plan, the private company offering your Plan will take over some of the administrative processes to implement your Medicare benefits; however, you do not lose your Original Medicare. Later, if you wish to leave a Medicare Advantage plan, you can return to your Original Medicare Part A and Part B coverage during either the Annual Coordinated Election Period (AEP) (October 15th through December 7th) .
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What are the types of Medicare Advantage Plans?
There are only a few primary types of Medicare Advantage Plans and most of the different Medicare Advantage Plans may also include prescription drug coverage:
- Health Maintenance Organization (HMO) - A Health Maintenance Organization that is contracted with Medicare provides you with access to a network of doctors and hospitals that coordinate your care, with an emphasis on prevention. This allows you to get more benefits than the Original Medicare Plan and many Medicare Supplement plans. An HMO has the tightest or most restrictive network where your care may not be covered if you go outside the HMO network without obtaining prior approval.
- Health Maintenance Organization with a Point of Service Option (HMO POS) - This is a Health Maintenance Organization that provides a more flexible network allowing you to seek care outside of the traditional HMO network under certain situations or for certain treatment. You may pay some additional fees for using the POS (out-of-network) option.
- Preferred Provider Organization (PPO) - A Preferred Provider Organization provides access to a network of doctors and hospitals that coordinate your care. As with an HMO, a PPO allows you to get more benefits than the Original Medicare Plan and many Medicare supplement plans. PPOs have a network of doctors and facilities, but also allow you to use any doctor or hospital outside of the network for a higher copay or coinsurance.
- Private Fee-For-Service (PFFS) - A Private Fee-For-Service Plan is a type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts both Medicare and the plan’s payment (or terms and conditions). The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn’t cover. The PFFS Plans are the most flexible, but a doctor or hospital can make patient-by-patient or visit-by-visit decisions of whether to accept the PFFS Plan Member.
- Medicare Special Needs Plans (SNPs) - A Special Needs Plan is a Medicare Advantage Plan with coverage designed especially for Medicare beneficiaries with certain chronic conditions (like Diabetes) or have some other specific need. Usually only people with certain conditions or needs are allowed into a SNP.
- Medicare Medical Savings Account (MSAs) - A Medical Savings Account is a combination of a high-deductible health plan and a bank account where your Plan deposits a certain amount of money per year. You use the money in your account to pay for Medicare Part A and Medicare Part B expenses, and when your Plan deductible is met, the Plan pays for any further Medicare-covered services. MSAs are only MAs and not MA-PDs. That is, MSAs do not offer Medicare Part D prescription drug coverage.
Does each Medicare Advantage Plan offer the same type of health coverage?
No. Each Medicare Advantage Plan is different. Although all Medicare Advantage Plans must cover at least the Medicare Medically-Necessary Services, Medicare Advantage Plans can charge different deductibles, offer co-payments (for instance $30 per office visit) or various co-insurance terms (such as 20% of the procedure cost). Some Medicare Advantage Plans have a limit on how much you can spend in a year and some MAs do not have a limit on spending. Medicare Advantage Plans also offer additional services like eye care, dental care, and fitness programs.
Bottom Line: Be sure to understand the coverage before enrolling - if you are unsure, ask questions or telephone Medicare at 1-800-633-4227 for assistance.
How does a person choose a Medicare Advantage Plan?
It is of course important to compare the benefits between your current coverage and the Medicare Advantage Plan. Be sure that you understand the additional benefits and any benefits (or freedoms) that you may loose. In general, we usually remind people to look at the Cost, Coverage, Convenience, Company reputation, and Comments from other Members. In particular, be sure to look at the following:
- Can you change your current doctor(s) or are they in the new plan’s network?
- If prescription drug coverage is provided, are your medications on the plan’s formulary?
- How much is the monthly premium?
- How much will your coverage cost? Co-payments and co-insurance as explained in the plan’s Summary of Benefits.
- Which additional services are offered, such as preventative care, vision, dental, and health club membership.
- Are there any treatments that you need that are not covered by the Plan?
- Can you work within the network restrictions (like paying extra when you visit a doctor who is out-of-network)?