OVERVIEW OF MEDICARE ADVANTAGE
Medicare Advantage (previously Medicare Plus Choice) includes Medicare Managed Care Plans provided through a Health Maintenance Organization (HMO), Preferred Provider Organization Plans (PPO), Medicare Special Needs Plans & Private Fee-for Service Plans.
HMO Plans must cover all of the benefits that original Medicare A & B cover. In fact, some HMO Plans may cover extra benefits like an annual physical exam or vision exam. An HMO also may have a lower premium than traditional Medigap plans. However, HMO Plans differ from Original Medicare in that , except in emergencies or certain cases where care is urgently needed, the beneficiary can only go to doctors, specialists and hospitals on the plan’s list. They use a limited network of health care providers and facilities and a system of “prior approval” from a primary care physician, sometimes referred to as a “gatekeeper” to achieve these goals.
When you are enrolled in a Medicare Advantage Plan:
- You remain enrolled in Medicare but are now receiving your healthcare benefits through the Managed Care Plan.
- Unlike with a Medigap policy, Medicare is not the primary payor when someone enrolls in a Medicare Advantage Plan.
- The beneficiary must remain enrolled in both Medicare A and Medicare B and receives all of the rights and benefits entitled under Original Medicare.
- A beneficiary enrolls in either the Original Medicare or a Medicare Advantage Plan BUT NOT BOTH
Possible Advantages of Medicare Advantage Plans:
- Emphaisis on preventive care
- Health and prescription benefits can be obtained all under one plan
- Additional benefits may be offered such as vision, hearing and dental. (see individual plans for details)
Possible Disadvantages of Medicare Advantage Plans:
- Limitations on procedures for receiving specialized care
- Must use plan providers only with out-of-area care limitations
- Providers can terminate their contracts with plans during the course of the benefit year
- Plans may change their benefit packages, premiums, payments and service area annually
- Disenrollment issues, lock-in provisions and regulatory authority
Considerations Before Enrolling in a Medicare Managed Care Plan
- Read the membership materials carefully
- Determine the nature and extent of the plan coverage
- Compare benefits, costs and features of a plan for a price the beneficiary can afford
- Check with the plan physicians and other providers (such as hospitals and pharmacies) and determine if they are participating providers in the plan network
- Learn how to use the plan complaint system, and how grievances and appeals are handled
For additional information regarding Medicare Advantage Plans contact: