Medicare is a federal health insurance program that is available for Americans aged 65 and older, or people under 65 who have disability or end-stage renal disease. There are several different components to Medicare Plans. Parts A and B are part of Original Medicare insurance. Medicare Part C adds routine dental, vision, hearing and prescription drug coverage through a private insurance company. Part D only covers prescriptions drugs and is considered supplemental from the Original plan.
What is Part C?
Medicare Part C, also referred to as Medicare Advantage, is a plan sold through private insurance companies contracted with Medica. This private health insurance plan is for individuals seeking additional coverage beyond Original Medicare Part A (hospital insurance) and Part B (medical insurance) plans. Selection of Part D, Prescription Drug Coverage, is generally not available when enrolled in a Medicare Advantage plan nor are Medi-gap policies.
Enrollment into a Medicare Advantage plan is available when:
*You are currently enrolled in Medicare Part A and Part B
*You live in the service area of the plan you want to join
*You do not have End-Stage Renal Disease (ESRD)
Each type of plan offers specific coverages varying state to state and generally include the benefits of routine dental, vision, hearing, and many include prescription drug coverage. Care is provided by a plans network rules. Most states offer up to ten standardized plans, meaning the details of the plan do not change from state to state. It is important to review available options where you live to choose a plan that best fits your needs.
Here is a brief description of common plan options available.
Health Maintenance Organization (HMO) – An organization providing health coverage under contract. The plan administrator supplies a list of network physicians, hospitals and pharmacies that provide services in a certain part of the country. There is not coverage for out-of-network services except in emergency situations or if you have a Point of Service option. Consult your plan specifics, as HMO’s may vary in coverage levels.
Preferred Provider Organization (PPO) – An organization allowing participants to choose doctors and hospitals they prefer. Availability to out-of-network care increases the amount you will pay, unless it is an emergency./,
Private Fee-for-Services (PFFS) – A plan that determines the amount to pay health care providers and the amount participants pay when care is administered based on prior authorization. Prescription drugs may be covered under this plan. If not, enrollment into the Medicare Part D is necessary to obtain prescription drug coverage.The provider, hospital and pharmacy must agree to treat based on pre-approval.
Special Needs Plans (SNP) – An HMO plan for Medicare to offer tailored coverage to participants with specific diseases or characteristics, including prescription drug coverage. Ask about the plans specific network rules.
Medical Savings Account (MSA) –A savings account provided by carrier that accepts tax-deferred deposits to assist with high-deductible medical insurance. Doctor or hospital care is available when a provider accepts the plans fees. Ask about the plans specific network rules.
How Do I Enroll?
Opportunity to enroll in the Medicare Advantage program is offered during these periods.
Initial Coverage Election Period (ICEP) – Enrolling in Medicare Part C during the ICEP is the same as Original Medicare. The initial enrollment period includes the three months before 65th birthday, the month of birthday and continues for another three months, for a total initial enrollment period of seven months.
If your covered through an employer during the ICEP, then a three month window is granted before the Plan B effective date to elect Part C coverage.
Annual Election Period (AEP) – If you choose to enroll in Advantage after enrollment into the Original plan, then you must wait until Open Enrollment Period, referred to as Annual Election Period, runs from October 15 to December 7 each year. During this time, additions, deletions, and modifications may be made to the plan that takes effect January 1.
Special Enrollment Period (SEP) – Life events may create a need to enroll or modify Medicare coverage within plan period. These events may include:
*Losing current health coverage
*Eligibility in another type of plan
*Change in current plan that affect health benefits.
Can I change my plan?
Advantage Plan changes can only take place during the Fall Open Enrollment Period, but doctors and hospitals may leave the plan at any time. Since you typically pay less to see a provider that is in-network, the plan must try and notify you in writing of the change at least 30 days of the provider leaving. The notice advises timeframe to connect with another in-network provider to retain the lower cost.
There are other times when a formulary change occurs mid year that may alter plan options as well.
When a drug is declared unsafe, the Food and Drug Administration (FDA) may remove it from an approved list. This will also change the formulary, and notification must be given to those prescribed the medication.
If there is a plan change due to maintenance, the plan has 60 days to notify you of the change or provide with a 60-day transition fill. If the change is not due to maintenance, all coverage will remain unaltered for the rest of the year until medically necessary. At that time, written notice must be supplied with the same 60-day window.
Renewing My Plan
Every January, the Advantage plans are reviewed by Medicare to verify coverage and costs are appropriate for the upcoming year. The health plans are placed into a star rating system for ease in selection at election time. It is important to review current coverage during the Annual Election Period (AEP) and compare it other plans that are available in your area. Medicare makes the comparison easy by using star ratings on their health plans based upon:
- Staying Healthy: screening, Tests and Vaccines
- Managing Chronic (Long-Term) Conditions
- Plan Responsiveness and Care
- Member Complaints, Problems Getting Services, and Choosing to Leave Plan
- Health Plan Customer Service
Medicare drug plans are rated on how well they perform in four different categories:
- Drug Plan Customer Service
- Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
- member Experience with Drug Plan
- Drug Pricing and patient Safety
Canceling Medicare Part C
Members of the Advantage plan with or without drug coverage may disenroll during the Medicare Advantage Disenrollment Period (MADP) from January 1 to February 14 each year. When disenrolled, coverage reverts back to the Original Medicare plan in place before Part C coverage took place and the plan will be serviced by Medicare. Enrollment in Medicare Part D may be necessary when prescription drug coverage is needed.
If you are enrolled in a PFFS with a stand alone drug plan, there will be no change to the drug coverage plan in place.
If you disenroll in the Medicare Advantage plan, federal law prohibits enrollment into a medigap plan. Consult your State Health Insurance Assistance Program for state guidelines on enrollment opportunities.
If you’re interested in finding out more about medical supplement insurance plans, consult the following resources below:
- 800-MEDICARE (800-633-4227)
- State contacts: http://www.medicare.gov/contacts/organization-search-criteria.aspx
- State Health Insurance Assistance Program (SHIP)
Other Enhanced Insurance articles related to Medicare Insurance:
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