If you are 65 years of age or older, or have a disability, you may qualify for Medicare. There are two types of Medicare to choose from: Original and a Medicare Advantage Plan.
Original Medicare covers Parts A and B, which includes both hospital and doctor visits. It also covers durable medical equipment, certain medications like the annual flu shot, and preventative health services. Each part has its own monthly premium.
Medicare Advantage differs from Original Medicare in that Parts A and B are packaged together and offered through private healthcare insurers. The Medicare Advantage Plan is often referred to as Part C. These companies are contracted through Medicare to ensure that the benefits are similar to the Original plan. It gives you the choice to enroll in a Medicare managed plan and/or add additional coverage like dental and vision. This covers emergency and urgent care visits, as well as all of the Original Medicare services except hospice care.
What are my plan options?
If you decide to purchase a Medicare Advantage Plan, you have several different options to choose from, including HMO, PPO, PFFS, and SNP. Each plan type is explained below.
The Health Maintenance Organization Plan, or HMO, involves a network of physicians, clinics, and hospitals. If you choose this option, you will be restricted to health care from the approved list of providers. This means that, if you already have a primary care doctor or preferred clinic, you should make sure that they are included within the HMO network. Otherwise, you will have to switch to a new set of doctors.
Traveling outside of your network while on an HMO plan can be tricky. In general, you are permitted to visit an emergency room or urgent care facility that is out-of-area for certain services. Of course, your HMO would never prevent you from seeing a doctor if you are away from home and have a pressing health issue. However, you will be obligated to pay full cost if you visit a non-network doctor for non-emergency purpose.
A Preferred Provider Organization Plan, or PPO, differs from an HMO in that you have some flexibility in your choice of doctors and clinics. A PPO will still have an established network of doctors, but you can arrange a visit with an out-of-network physician for an additional cost. Another advantage to a PPO is that you do not have to select a primary care doctor or get a referral to see a specialist. Under the HMO, you are required to have both. This means that you can see a dermatologist, endocrinologist, or any other specialist without first seeing your primary care doctor.
Of course, with these added benefits comes an added cost. You will have to explore the Medicare Plan Finder website, putting in your personal information and current medical needs, in order to compare specific cost differences between an HMO and PPO in your state.
The Private Fee-for-Service Plan, or PFFS, differs greatly from the HMO and PPO plans. Rather than having a specific network of providers, you can visit any doctor, clinic, or hospital that you prefer. So long as that provider is Medicare-approved, you may visit them for your healthcare needs.
The payment structure varies, depending upon the doctor or clinic you visit, and the services or tests you receive while visiting. The plan has a set list of how much you will pay for each doctor and service.
Some PFFS plans have a network of doctors, which may lower your costs. This is something to consider if you are concerned about your monthly healthcare premiums.
Special Needs Plans (SNPs) are for individuals who already have a particular disease or condition that requires special attention. You can purchase an SNP if you already reside in a nursing home facility, qualify for both Medicare and Medicaid, or have a qualifying chronic condition. If you live in a nursing home or have Medicaid, make sure that your doctors are within the SNP network.
The plan offers some flexibility to tailor your network of doctors and hospitals to those who specialize in your particular ailment. You will still be limited to that particular network, unless you have an emergency or need urgent care. Like the HMO plans, you will still need to have a designated primary care physician, and require a referral when seeing a specialist for the first time.
The less-common Medicare Advantage Plans include:
- HMO Point of Service (HMOPOS) Plans: An HMO plan that may allow you pay get some out-of-network services.
- Medical Savings Account (MSA) Plans: This combines a high-deductible health plan with your bank account. Medicare deposits money into the account which you can then use to pay for health care services.
What about Medicare Part D?
Most Medicare Advantage Plans include Medicare Part D as part of the health insurance coverage. You will need to verify with the company offering your desired plan in order to ensure that it includes prescription drug coverage.
How much does it cost?
There are many variables to consider when determining the overall cost of your Medicare Advantage Plan. Factors for your total plan costs include: monthly premium, Medicare Part B as a separate charge, annual deductible, copayment or coinsurance, the health services you use, in-network vs. out-of-network doctors you use, any extra services, whether or not you have Medicaid. Each plan is different and sets the deductible, premium, and services each year. You will need to review your selected plan coverage and costs before your purchase.
Who can join?
Anyone can purchase a Medicare Advantage Plan if you already have an existing Original Medicare Plan and want to switch. The plan you select has to be within your service area and you cannot already have End-State Renal Disease.
It’s easy to sign up. Simply join during the pre-determined enrollment period. To see which plans are available, go to the Medicare Plan Finder website.
It is uncommon for a Medicare Advantage Plan to end its Medicare affiliation. Do not worry if your plan no longer is available. At the end of the year, you will be automatically enrolled in Original Medicare and will have the option to purchase Part D.
How does Part C compare to Medigap?
A Medicare Advantage plan is similar to Medigap (also called Medicare Supplement) in that you purchase the policy through a private insurer. However, it differs on the types of benefits provided.
It is important to know the differences between Medicare Supplement and Advantage plans. They each have their own benefits- and their own costs.
|More expensive||Less expensive|
|Significant additional coverage to Medicare||Offers the same or similar coverage as Medicare|
|Larger network of providers||Smaller network of providers|
|No RX coverage||May include RX coverage|
|Recommended, if it is in your budget||Recommended for those on a smaller budget|
For more information, contact the Medicare Part D hotline at 1-800-MEDICARE, or 1-800-633-4227. You can also visit the Medicare website at www.medicare.gov.
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