Medicare Advantage plans are an alternative to getting original Medicare coverage and other benefits outside the range of an original Medicare plan. While part of Medicare, these plans are offered through approved private insurance carriers.
The bundled plan includes hospital insurance (Part A), medical insurance (Part B), and drug coverage (Part D). Most MA plans offer benefits, such as discounts on fitness programs and visual, auditory, and dental services. Some offer coverage for transportation to doctor visits, over-the-counter drugs, and wellness programs.
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How These Plans Work
Medicare is available to individuals aged 65 and older, with qualifying disabilities, and with end-stage renal disease (ESND). To enroll in an MA plan, you must enroll in original Medicare. The MA plan sets an annual limit on out-of-pocket costs, but this varies depending on the plan.
For some Medicare Advantage plans, you may have to pay a deductible, co-pays for services, and a monthly premium may apply. Each MA plan has different rules of engagement. Typically, it requires you to make use of in-network healthcare providers. However, some plans cover services from out-of-network providers but at an extra cost.
During open enrollment in Medicare, finding the best plan means putting your needs and preferences first; researching available MA plans; and understanding each plan’s terms, benefits, limitations, and criteria before enrolling. You should also consider factors such as:
- The convenience of switching primary care physicians if they are not Medicare providers
- Special medications/treatment for pre-existing conditions
- Whether you reside in the plan’s service area, which is usually based on the county or state in which you live
Types of Medicare Advantage plans
1. Health Maintenance Organizations (HMOs)
Enrolling in a Health Maintenance Organization (HMO) plan provides in-network coverage for care services. Still, out-of-network services are covered out of pocket, except in emergency care and dialysis cases. You’ll also be required to choose an in-network primary care physician (PCP) who will serve as your first point of contact for health-related issues. But to see a specialist, you’ll need to obtain a referral. An HMO typically covers prescription drugs (Part D), but if you purchase an HMO that doesn’t cover this, you won’t be eligible to purchase a separate Part D plan. HMOs offer low premiums, deductibles, and co-pays.
2. Preferred Provider Organizations (PPOs)
Taking part in a preferred provider organization (PPO) plan offers you a wider range of providers and services. You can use any in-network provider and access out-of-network coverage — but at a higher cost. Unlike an HMO, you don’t need a referral to visit an in-network specialist. However, these plans typically carry higher deductibles, premiums, and co-pays.
3. Private Fee-for-Service (PFFs)
Private fee-for-service plans determine how much they will pay healthcare providers and how much you must pay out of pocket when receiving care. You don’t need to choose a PCP or a referral to see a specialist. Also, you can visit any provider or hospital within the plan or outside the network as long as they agree to the plan’s payment terms. Finally, you can purchase a separate Part D plan if your PFF does not cover prescription drugs.
4. Special Needs Plans (SNPs)
This plan limits membership to people with specific diseases. The benefits, choice of providers, and drug formulation are tailored to meet the needs of specific conditions. All SNPs provide Part D coverage. However, only some cover out-of-network services, require you to choose a PCP and require referrals to visit a specialist.
Do Your Research to Select the Best MA Plan
Comparing health and drug plans to find coverage that meets your needs isn’t always easy. There are many moving parts and options to consider. However, if you conduct some thorough research and directly contact the plans you’re interested in for detailed information about costs and coverage, you’re bound to make an informed decision for your health and well-being.
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