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Medicare Advantage Plans

Medicare Advantage Plans are a type of Medicare health plan offered by a private company that contracts with Medicare to provide all your Part A and Part B benefits. Most Medicare Advantage Plans also offer prescription drug coverage. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan. Your Medicare services aren’t paid for by Original Medicare.

Health Maintenance Organization (HMO) Plans

In HMO Plans, you generally must get your care and services from providers in the plan’s network, except:

Emergency care
Out-of-area urgent care
Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.

Preferred Provider Organization (PPO) Plans

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.

Private Fee-for-Service (PFFS) Plans

A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Special Needs Plans (SNP)

Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. and tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.

Other

Other less common types of Medicare Advantage Plans that may be available include HMO Point of Service (HMOPOS) Plans and a Medicare Medical Savings Account (MSA) Plan

Medicare Part D – Prescription Drug Plans

Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different “tiers” on their formularies.

List of Covered Prescription Drugs (formulary)

The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer.

The formulary might not include your specific drug. However, in most cases, a similar drug should be available. If you or your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.

A Medicare drug plan can make some changes to its drug list during the year if it follows guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new drugs are released, or new medical information becomes available.

Generic Drugs

The Food and Drug Administration (FDA) says generic drugs are copies of brand-name drugs and are the same as those brand-name drugs in:

dosage form
safety
strength
route of administration
quality
performance characteristics
intended use

Generic drugs use the same active ingredients as brand-name prescription drugs. Generic drug makers must prove to the FDA that their product works the same way as the brand-name prescription drug. In some cases, there may not be a generic drug the same as the brand-name drug you take, but there may be another generic drug that will work as well for you. Talk to your doctor or other prescriber about your generic drug coverage.

Tiers

To lower costs, many plans offering prescription drug coverage place drugs into different “tiers” on their formularies. Each plan can divide its tiers in different ways. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.

Here’s an example of a Medicare drug plan’s tiers (your plan’s tiers may be different):

Tier 1—lowest copayment : most generic prescription drugs
Tier 2—medium copayment: non-preferred generic prescription drugs
Tier 3—higher copayment: preferred, brand-name prescription drugs
Tier 4—Non-preferred, brand-name prescription drugs
Specialty tier—highest copayment: very high cost prescription drugs

In some cases, if your drug is in a higher (more expensive) tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you can file an exception and ask your plan for a lower copayment.

Remember, this is only an example—your drug plan’s tiers may be different.

Home Health Care

Insurance plans, often referred to as short-term home health care coverage, may be available in your area to help cover the costs of deductibles and co-payments for home health care services provided by a Licensed Health Care Practitioner. In many cases, benefits are paid directly to the insured, regardless of any other insurance you many have.

Burial & Final Expense

Burial or cremation and other final expense costs are not covered by Original Medicare or Medicare Advantage Plans. Some private life insurance companies offer coverage for this need. Some plans’ qualifications may include health questions to determine eligibility or premium.

Medicare Supplement Insurance Plans

Medicare Supplement Insurance help fill “gaps” in Original Medicare and is sold by private companies. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like:

Copayments
Coinsurance
Deductibles

Some Medigap policies also cover services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, here’s what happens:

Medicare will pay its share of the Medicare-approved amount for covered health care costs.
Then, your Medigap policy pays its share.

Hospital Plans

Depending on the state you live in and the insurance carrier some insurance plans may be available to help cover out-of-pocket expenses for hospital care and fill all or some of the gap in most Medicare Advantage Plans. Many hospital plans are indemnity type plans, meaning they pay the insured directly, regardless of other insurance coverage. Health questions may be included to determine eligibility.

Dental, Vision, Hearing

Original Medicare does not cover normal dental, vision or hearing costs. Some Medicare Advantage Plans may offer some coverage to these costs. Insurance and discount plans are available through private insurance companies to help cover these costs. These companies determine what the plans will cover, if there will be a deductible or co-pay, and how much the premiums will be. Some plans may exclude some pre-existing conditions.

Spirit Dental

Cancer, Heart Attack, Stroke

Original Medicare and Medicare Advantage Plans pay part of cancer treatments. Other cancer insurance plans are built to pay a lump-sum benefit to help pay coinsurance and co-payments often accompanying cancer treatments. Plans may also be available in your state to cover advanced screening. Qualification includes pre-existing condition look-backs. Contact us for details of these plans and availability in your state.

Insurance may be available in your state to help cover co-payments and/or coinsurance for on-going doctor, clinic and hospital visits after suffering a heart attack or stroke. Most plans pay a one lump sum benefit regardless of any other insurance benefits.

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Frequently Asked Questions

what is a medicare advantage plan?

Medicare Advantage Plan, also known as Part C, is a Medicare Plan run by private insurance companies. A Medicare Advantage Plan offers all of the benefits covered under Original Medicare and more. Medicare pays a fixed fee to the plan you choose in accordance with the 2003 Medicare Prescription Drug, Improvement, and Modernization Act. It covers all of the benefits covered under original medicare and more, like Dental, Hearing and Vision.

Where can I get help paying for Medicare?

Financial assistance programs for people with limited income and assets include:

Extra Help is a program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance. If you get Extra Help but you’re not sure if you’re paying the right amount, call your drug plan. Your plan may ask you to give information to help them check the level of Extra Help you should get.

Medicaid is a joint federal and state program that:

Helps with medical costs for some people with limited income and resources
Offers benefits not normally covered by Medicare, like nursing home care and personal care services

In some cases, Medicare Savings Programs may also pay Medicare Part A and Medicare Part B deductibles, coinsurance, and copayments if you meet certain conditions.

Programs of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility. With PACE, you have a team of health care professionals working with you and your family to make sure you get the coordinated care you need. Usually they care for a small number of people, so they really get to know you. When you enroll in PACE, you may be required to use a PACE-preferred doctor.

What is the difference between Medicare & Medicaid?

Medicare and Medicaid are both government health care programs but they are very different. Medicare is generally for people who are older or disabled. Medicaid is for people with limited income and resources. When a person qualifies for both programs out-of-pocket costs can be minimal.ps.

I am Disabled - when can I get Medicare?

You automatically get Part A and Part B after you get one of these:

Disability benefits from Social Security for 24 months
Certain disability benefits from the RRB for 24 months

You don’t need to sign up if you automatically get Part A and Part B. You’ll get your red, white, and blue Medicare card in the mail 3 months before your 25th month of disability.

When you decide how to get your Medicare coverage, you might choose:

A Medicare Advantage Plan (Part C)
Medicare prescription drug coverage (Part D)

There are specific times when you can sign up for these plans, or make changes to coverage you already have.

8 Things to Know About Medicare

You must have Medicare Part A and Part B.
A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.
You pay the private insurance company a monthly premium for your Medigap policy. You pay this monthly premium in addition to the monthly Part B premium that you pay to Medicare.
A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you’ll each have to buy separate policies.
You can buy a Medigap policy from any insurance company that’s licensed in your state to sell one.
Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.
Some Medigap policies sold in the past cover prescription drugs. But, Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).
It’s illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you’re switching back to Original Medicare. In other words, you cannot have both a Medigap policy and a Medicare Advantage Plan.

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