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Medicare Part C Advantage Plans

Advantage Plans are all inclusive Medicare Plans called Medicare Part C.  They are offered by private insurance companies but are not supplement insurance plans. They are stand-alone Medicare Plans that replace your original Medicare Parts A, B, and sometimes D and they are called Advantage Plans Medicare Part C.  You still have to sign up for Medicare Parts A and B but you cannot use your original Medicare card; put it in a safe place in case you want to use it later.  When you have an Advantage Plan your Medicare card is issued by the insurance company under its name.

Advantage plans are Medicare plans (not original Medicare) and as such they have the same Enrollment Period; three months before your 65th birth month and three months after.

Key Points:

  • You are always covered in an emergency if it is an emergency a hospital cannot refuse you if you are on Medicare.
  • Advantage Plans must cover all the services that original Medicare covers except hospice care and some care associated with clinical research studies.
  • Most Advantage Plans include your drug Plan (Part D).
  • Advantage Plans may offer extra coverage like hearing and wellness programs.
  • Most Advantage Plans are HM0’s or PPO’s and while governed by Medicare they set their own rules and pricing but the maximum out-of-pocket you can incur annually is $6,850 (2015).
  • You have the same rights and protections as original Medicare.
  • If you join an Advantage Plan for the first time and are not happy with the plan you have the right to buy a supplement policy within the first 12 months of joining.
    • If you had a supplement policy before you joined the plan you may go back to the original supplement policy if it is still offered.  If no longer offered you may get another policy.
    • If you joined an Advantage plan when you first went on Medicare you can choose from any supplement plan.
  • Annually between January 1st and February 14th if you have an Medicare Advantage Plan you can switch from that plan only to original Medicare (and a Medicare Supplement if you want).  You must also join a Medicare Drug Plan (Part D) by February 14th if you are leaving an Advantage Plan
  • Advantage plans each have a medical network and they may change approved doctors at anytime during the year.
  • You have to choose a primary care doctor from the plans network.
  • Advantage plans cannot charge more than original Medicare for certain services.

Below is a short definition of each type of Advantage Plan:

  • Health Maintenance Organization:  HMO – You have to use doctors or facilities identified in the plan’s network.  There usually is not an out-of-pocket co-pay for each visit.  This plan does not normally require additional premium other than that provided by your Medicare Part B premium.
  • Preferred Provider Organization: PPO – They have a network of preferred providers and if you use in network doctors and facilities you pay less out-of-pocket.  However, you can go out of network but if you do, you will have to pay higher out-of- pocket co-pays.  There is usually an additional premium for these type of plans.
  • Private Fee-for-Service:  PFFS – These plans have the same rules as under original Medicare and you need to go to the plans network doctors and services and the plan decides what you will pay for their services.
  • Special Needs Plans:  SNPS – They are special Plans for special groups of people; like those who have both Medicare and Medicaid, live in a nursing home or have certain chronic health conditions.  For more information on these plans, visit Medicare.gov/publications.
  • HMO Point-of Service Plans:  HMOPOS – There are HMO’s (not many) that may allow you to get some services outside the network for a higher co-pay.
  • Medical Savings Account Plans:  MSA – Combine a high-deductible health plan with a bank account.  For more Information on these plans, visit Medicare.gov/publications.
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