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Introduction
Medicare Advantage Plans are Managed Care plans that might be thought of as a combination insurance company and a health care delivery system all in one. Like an insurance company, they cover health care costs in return for a monthly premium and like a doctor or hospital, they provide health care services.
Each Medicare Advantage Plan has its own network of hospitals, skilled nursing facilities, doctors and other health care professionals. Services must usually be obtained from the professionals and facilities that are part of the plan.
When you first enroll in a Medicare Advantage Plan, you will be asked to select a primary care doctor from their list of doctors. A primary care doctor is responsible for managing all of your medical care and when necessary, admitting you to a hospital. If you should ever need to see a specialist, like a cardiologist or an orthopaedic surgeon, your primary care doctor will help you choose one and also make the referral.
Medicare Advantage Plans generally charge enrollees a monthly premium although some plans may offer coverage with "0" premium. Premiums vary from plan to plan and may change annually.
Medicare Advantage Plans may also charge a small co-payment each time an enrollee uses a service, e.g., $10.00 for a visit to the doctor, or $5.00 for each time you have a prescription filled. There are usually no additional charges by the Medicare Advantage Plan.
Depending on how the plan is organized, the services are generally provided either at one or more centrally located health facilities or in the private practice offices of the professionals affiliated with the plan.
[Back to the questions]
| How do Medicare Advantage Plans Work? |
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| Medicare beneficiaries can elect to join a Medicare Advantage Plan as an alternative to traditional fee-for-service Medicare. Medicare Advantage Plans contract with the Centers for Medicare and Medicaid Services to provide the full range of Medicare-covered services to Medicare beneficiaries for $.00 cost or a fixed monthly fee.
The Centers for Medicare and Medicaid Services pays a single fee every month to the Medicare Advantage Plan for taking care of you, whether you receive any health care services or not. The Medicare Advantage Plan pays the physicians and hospitals that belong to the Medicare Advantage Plan in much the same way - so no one has to file any insurance claims.
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[Back to the questions]
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Am I Eligible to Enroll
in a Medicare Advantage Plan?
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The only requirements for you to enroll in a Medicare Advantage Plann are:
- You must at least be enrolled in Medicare Part A (this part pays the Hospital bills)
- You must also be enrolled in Medicare Part B (this part pays the medical or doctor bills) and continue to pay the Part B monthly premium. For 2006, the premium is $88.50 and in most cases is automatically deducted from your social security check.
- You must live within the area in which the plan has agreed to provide services.
- You cannot be medically determined to have end-stage renal disease (ESRD).
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[Back to the questions]
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How Can I Join a Plan and
When Does My coverage Begin?
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| You can get the names of the Medicare Advantage plan(s) in your area by calling Paul Thordsen 281-907-0072 or Toll Free 1-275-9840 or by calling 1-800-MEDICARE, or through the Internet at www.medicare.gov.
You may choose to have coverage begin either the first day of the month after your enrollment application is received by the Medicare Advantage plan provider or up to three months later. The Medicare Advantage plan provider must give you written information explaining your coverage and when it goes into effect. The Medicare Advantage plan provider must also supply you with membership materials that give you full details on your Medicare appeals rights for filing complaints.
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[Back to the questions]
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If I Enroll, Where Do I Go For Care?
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| As an Medicare Advantage member, you generally must receive all covered care through the plan or from health care professionals to whom the plan refers you if the plan is to pay for your care.
With few exceptions, if you go outside the plan for services, neither the Medicare Advantage Provider nor Medicare will pay for those services. You will have to pay the entire bill out of your own pocket. The only exceptions are for emergency services, which you may receive anywhere in the United States, and urgently needed care, which you may receive while temporarily away from your Medicare Advantage service area.
If you are in a Medicare Advantage Area with a Point of Service option you can go to doctors and hospitals who are not part of the plan ("out-of-network"), but you may pay extra. Check with your Medicare Advantage care plan for more information.
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[Back to the questions]
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How Do I Disenroll?
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If you enroll in a Medicare Advantage plan and later decide to join Original Medicare (traditional fee-for-service), you must state in writing that you want to withdraw from the Medicare Advantage Plan to join Original Medicare.
Give the written statement either to the Medicare Advantage administrative office or to your local Social Security Administration Office or, if appropriate, your Railroad Retirement Board office. Your coverage under Original Medicare will begin the first day of the following month.
If you want to change from one Medicare Advantage Plan to another, you may do so by simply enrolling in the other Medicare Advantage plan. This will automatically disenroll you from the first plan.
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[Back to the questions]
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What Are Some Advantages of Medicare Advantage Plans?
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- You will not need Medigap insurance which is costly.
- Medicare Advantage Plans may not health screen - therefore you may not be denied enrollment due to your health condition.
- You will not have to deal with Medicare paperwork.
- You will not have to pay the Medicare deductibles and coinsurance.
- You may receive coverage for services that traditional fee-for-service Medicare does not cover. For example, some Medicare Advantage Plans offer benefits such as routine physical exams, eyeglasses, hearing aids, prescriptions, and dental coverage.
- Some offer free transportation to medical facilities, pharmacies etc.
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[Back to the questions]
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What Are Some Disadvantages of Medicare Advantage Plans?
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- You are not free to receive care from any doctor, health care provider, or hospital you choose.
- You will only be covered for health care services received through the Medicare Advantage Plan, except in emergency and urgent care situations.
- In order to receive coverage for a specialist's services, have surgery, or obtain medical equipment or any other health care service, you will need prior approval of your primary care doctor.
- If you are out of the Medicare Advantage Plan service area, you will not receive coverage for your care except in emergency and urgent care situations.
- If you spend part of the year outside the Medicare Advantage Plan's service area, or expect to be away from the plan's service area for more than 90 days, joining a Medicare Advantage Plan may not be in your best interest.
- If you decide to switch from the Medicare Advantage Plans to traditional fee-for-service Medicare, your coverage will not begin before the first day of the month following receipt of your disenrollment request.
- If you have replaced your traditional fee-for-service Medicare plan and your medigap policy with a Medicare Advantage Plan, then decide to return back to them, your medigap insurer may then screen you for pre-existing conditions and may charge you a higher premium or deny you coverage.
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[Back to the questions]
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For More Information
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Every state, plus Puerto Rico, the Virgin Islands, and the District of Columbia, has a health insurance counseling program that can give you free information and assistance on Medicare, Medicaid, Medigap, long term care and other health insurance benefits.
For more information, or call the Medicare hotline at 1-800-MEDICARE.
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