Medicare Advantage health plans are health insurance policies offered by private insurance companies. This is a service distinct from the basic coverage offered by the federal government under Original Medicare. Original Medicare coverage falls under two categories or “parts”. Part A provides hospitalization insurance. Part B provides medical insurance.
Under basic Original Medicare, the beneficiary pays a premium to the Federal Government to receive benefits under Parts A and B, but then must pay any costs not covered, either through a co-pay, or by the purchase of supplemental insurance. Under Original Medicare, a beneficiary must also pay for prescription drugs.
Under a Medicare Advantage plan, the beneficiary still pays the premium to the Federal government, but receives coverage administered by a private insurance company. This coverage still includes the services under Parts A and B, but also covers prescription drugs, often called “Part D,” and co-payments. It frequently covers other services as well. Medicare Advantage plans are often referred to as “Medicare Part C.”
How do Medicare Advantage Plans Work?
Medicare Advantage plans provide the health coverage of Medicare Part A and Part B through private insurance companies. The insurance companies providing Medicare Advantage plans must follow rules which are set by the federal government.
If a person enrolls in a Medicare Advantage plan then he or she will have Medicare and will retain the health coverage provided in Part A and Part B. Man plans not only cover Part A and Part B, but also provide prescription drug coverage, known as Part D If a person’s particular plan does not include prescription drug coverage, then one can enroll in a New Jersey Medicare Part D plan that meets particular health care needs.
What additional services are covered in Medicare Advantage Plans?
Most Medicare Advantage plans provide various additional services that are not covered by Original Medicare such as
- Fitness programs, including discounts on gym memberships
- Vision, hearing, and dental services.
- Transportation expenses involved in doctor visits
- Over-the-counter drugs
- Services improving wellbeing, health, and wellness.
The supplemental services offered depending on the particular Medicare Advantage plan chosen. Some of the plans might also offer benefits to people suffering from chronic illnesses. Many plans can be personalized to treat particular conditions. Since plans very widely, each plan will have different out-of-pocket costs. Therefore, a person must always investigate a plan carefully before he or she enrolls. The best way to investigate a plan is to consult a reputable, established Medicare Insurance Agency that will help you understand the benefits you may qualify for if you sign up for a particular health care plan.
What are some of the rules for enrolling in Medicare Advantage Plans
Companies offering Medicare Advantage Plans are paid a fixed amount per member of the plan by the federal government. In return, these organizations must follow certain rules set by the U.S. Department of Health and Human Services.
The rules set by the federal government include rules dictating the provision of services; when a specialist may be consulted,; and when a beneficiary may see a doctor under non-urgent or non-emergency circumstances. The rules also cover the dispensing of drugs or other health aids if that coverage is selected.
Rules change and are updated frequently, and policy terms may change every year to reflect those updates.
How are Prescription Drugs Included in Medicare Advantage Plans?
Many Medicare Advantage plans provide Part D prescription drug coverage. However, there are also separate Medicare Prescription Drug Plans which offer only Part D prescription drug coverage. Such plans may be particularly advantageous for those with Medicare Medical Savings Account plans, which do not offer prescription drug coverage, or for those retaining private health insurance.
Can I lose a Medicare Advantage Plan and fall back into the Original Medicare System?
A Medicare Advantage plan can’t drop you because of a specific medical problem or ailment.
A Medicare Advantage plan can cancel your coverage or drop you if you fail to pay any premium you are responsible for within the time limit allowed by the policy.
If you move out of the area served by a particular plan, you may lose the benefit of coverage. Not all plans are available in all areas.
An insurance company may opt to discontinue a particular Medicare Advantage plan. Also, the Department of Health and Human Services Center for Medicare and Medicaid Services may elect not to renew the contract of an insurance provider.
If you have End Stage Renal Disease, you may not be able to purchase all regular Medicare Advantage plans, however you may qualify for a Special Needs Plan.
How can a person suffering from End-Stage Renal Disease (ESRD) join a Medicare Advantage Plan?
People not otherwise eligible for Medicare, who are suffering from ESRD may enrol in either the Original Medicare Plan or a Medicare Advantage Plan. A person is eligible for enrollment in Medicare (whether Original or Medicare Advantage) if:
- His or her kidney’s fail
- He or she needs regular dialysis
- He or she has had a kidney transplant
One of the following must also be true:
- He or she has worked for the required number of quarters to be eligible for Social Security or Railroad Retirement Board benefits, or has worked as a government employee.
- He or she is already getting benefits or eligible for benefits under Social Security or Railroad Retirement Board.
- He or she is a dependent child or spouse of a person who meets either of the two criteria listed above.
If a person with ESRD wishes to select a Medicare Advantage plan, they should always be aware that most Medicare Advantage plans are either preferred provider plans (PPO’s) or health maintenance plans (HMO’s). Such plans control costs by limiting the choice of doctors to a few select individuals or facilities. Thus you should always check in advance to see if your preferred specialists and facilities accept any particular plan before enrolling in it. Another alternative for a person with End Stage Renal Disease might be a Medicare Advantage Special Needs plan, tailored to their specific circumstances.
What are the Expenses for Medicare Advantage Plans?
What members of a plan pay will vary based on different factors. In most cases, a beneficiary must use the health care providers included within the plan network. Also, some services may not be covered in a given plan or fall outside the plan’s network or outside the service area. Therefore, a person always examine the plan and the network carefully in order to choose the plan wisely.
