MEDICARE ADVANTAGE PLAN

Medicare Advantage Plans combine Medicare Part A and Part B benefits into one plan. Most also include prescription drug coverage as well as additional benefits often with no additional premium.

Medicare Advantage plans are offered by private insurance companies approved by Medicare. Coverage and cost share vary from plan to plan.

Many Medicare Advantage plans contract with a network of doctors and hospitals to provide care to plan members. Plans may require members to choose a primary care doctor from the network to manage their care.

Each plan creates its own provider network. On most plans you pay less for care you receive from providers in the network than for the same care received from providers outside the network.

Some types of plans allow for more freedom in choosing providers, although the cost may be higher.

Medicare Advantage plans operate in defined geographic areas called “service areas”. You must live in the plan’s service area to become a plan member and in most cases receive your care in that service area.

Types of Medicare Advantage Plans

HMO Plans (Health Maintenance Organization Plans)

• Require you to seek care from providers in the network
• May require you to choose a primary care provider, who then manage any care you receive from specialists
• Requires referrals from your primary care provider to see specialist
• Do not cover any of the cost of care you receive outside the network, except for emergency care, urgent care and renal dialysis

PPO Plans (Preferred Provider Organization Plans)

• Offers more freedom in choosing doctors and other providers in or out of the network
• Don’t require a referral from your primary care provider to see a specialist
• Allow you to see providers outside the network, though you’ll usually pay more than you would with a network provider

SNP (Special Needs Plans)

• Are designed for people with chronic conditions
• May provide care managers or nurse practitioners to help members get the care they need
• Usually have plan-specific eligibility requirements

What you pay for on a Medicare Advantage Plan (Part C)

Premium

• You continue to pay your Part B premium and your Part A premium, if you have one, to Medicare.
• Medicare Advantage Plans (Part C) may charge a premium, though some do not.
• Plan premiums vary widely and can change from year to year.

Deductible

Some Medicare Advantage plans may charge a deductible. Deductibles may be applied to drug benefits and not to medical benefits when a plan covers both. Deductible amounts may vary widely from one plan to another.

Copay

Many Medicare Advantage plans may charge a set copay amount for doctor visits and other services rather than a percentage of the cost as in Original Medicare. Copay amounts vary from plan to plan.

Coinsurance

Copays are more common, but Medicare Advantage plans may set coinsurance terms for some services.

Out-of-pocket maximum

Medicare Advantage plans are required to set an out of pocket maximum. An out of pocket maximum is the total amount you might pay for covered health care services each year.

• Your plan pays all your covered costs for the rest of the plan period if you reach the out of pocket maximum.
• Medicare puts a limit on how high a plan can set its max out of pocket amount. Plan maximums may be lower than the limit
• Premiums payments, drug costs and the cost of extra services a plan my cover, like vision or dental do not count toward the maximum out of pocket.
• There is no out of pocket maximum on Original Medicare.