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What are Medicare Advantage (Part C) 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. Below are the most common types of Medicare Advantage Plans.

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.

Q: What are Medicare Advantage (Medicare Part C) plans?
A: These plans are optional private insurance coverage for people with Medicare. These plans provide an alternative way of receiving Medicare benefits directly through an insurance company.  Do not throw away your Original Medicare card. You are still enrolled in Medicare! If you ever leave the MA plan you will return to Original Medicare. Store your Medicare card in a safe place! 
Beneficiaries under Medicare Advantage plans continue to pay the Part B Medicare premium for Medicare. A Medicare Advantage plan can terminate at the end of the contract year if either the plan or CMS decides to terminate their agreement. Medicare Advantage plans are regulated by the federal governement rather than by the state.
Q: What do Medicare Advantage plans cover?

A: The private insurance company that sells you the plan must provide you all Medicare-covered services, and may offer other coverage as well, such as dental, vision, or Part D prescription drug coverage. The plan may charge you different deductibles and copayments or coinsurance than under Original Medicare. It also may have specific rules about which providers you may see for your care. 
Coverage also depends on the plans structure. Most Medicare Advantage plans have one of the following structures. Be sure you understand how the plan works, and any limits on providers you can see, before you join! 

  • Health Maintenance Organizations (HMOs): The plan covers care only with providers within the plan’s network. Plans also cover emergency and urgently needed care outside of the plan’s network.  Under most plans you must have a primary care doctor in the network, and some plans require that you get referrals from that doctor to see specialists. 
  • Preferred Provider Organization (PPO): Your costs are lower if you go to providers within the plan’s network, but the plan still covers some costs if you see providers outside the plan’s network. 
  • Private Fee-For-Service (PFFS): CMS does not require providers, including physicians, home health agencies, and equipment suppliers to accept the terms of a PFFS plan. It is critical to know that any provider may choose to accept or not accept the terms of the PFFS plan each time a patient visits the provider. Enrollees cannot trust that their preferred doctors and hospitals will remain PFFS providers even if they received covered services through these providers previously. 
Q: What questions should I consider when choosing between a Medicare Supplement and Medicare Advantage program?
A: 
  • Does my doctor take this plan?
  • If I qualify for the Low Income Subsidy or Extra Help from Social Security, how will this change my options and costs?
  • If I qualify for a Medicare Savings Program through Medicaid, how will this change my options and costs?
  • Will I be able to go to the provider or hospital of my choice?
  • Does my out-of-pocket cost grow if I use the plan more?
  • Is there an out-of-pocket limit per year? (This is a maximum amount I would have to pay out of pocket before the plan covers all care.)
  • Will I have coverage if I travel outside my immediate area?
  • Are there any protections (such as guaranteed renewability, etc.) for me in this plan? What are they?
  • Are there any extra benefits provided to me in this plan? What are they?
  • What is not covered?
  • Will I need to consider buying a Part D plan?
Q: Can I have both a Medicare Supplement (Medigap) plan and a Medicare Advantage plan?
A: Medigap plans do not fill gaps in Medicare Advantage plans. People with Medicare looking for other private insurance may choose between Medigap and Medicare Advantage plans, but cannot have both. 
Q: What is the Late Enrollment Penalty (LEP)?
A: While Part D is optional, some people who join Part D later than when they first qualify may have to pay a late-enrollment penalty.   
Q: If I choose a Medicare Advantage plan, do I have to keep it forever?
A: No. You can change plans every fall from October 15 through December 7. Your new plan starts Jan. 1. If you do nothing during this annual enrollment period, and your plan is offered for the following year, you will remain on the same plan subject to any changes noted for the new year. You may also make one enrollment election during January, February, or March and during that time move from one Medicare Advantage plan to another Medicare Advantage plan or move back to Original Medicare. Some people get additional chances to change (special enrollment periods) for other events (such as moving, qualifying for help with costs, etc.). To switch plans, just enroll in the new plan (do not disenroll from the old plan first). Medicare will disenroll you from the old plan when your new plan starts.

If you choose a Medicare Advantage plan when you first get Medicare and then decide within 12 months it is not right for you, you may have rights to rturn to Original Medicare and buy a Medigap plan instead. Also, if you left a Medigap plan for a Medicare Advantage plan, you might be able to return to that Medigap plan within 12 months. Keep in mind your premium could be different than when you left.
 
Q: What will a Medicare Advantage plan cost me?
A: Costs vary widely. These plans generally have a monthly premium, and may also have deductibles and copays or coinsurance. In many cases, plans with lower monthly premiums have higher deductibles, copays and coinsurance. 
If the plan includes Part D coverage you may have separate deductibles, copays, coinsurance, and a coverage gap (or donut hole) for your drug coverage. Medicare is phasing out the donut hole by 2020. You still pay your premiums for Medicare Part B (and Part A, if any). 
If you have a late-enrollment penalty for Part D, this will be added to your Medicare Advantage plan premium, if any.
Q: Can I buy a Medicare Advantage plan?
A: Yes, if you have both Medicare Parts A and B, and do not have End Stage Renal Disease (ESRD). You also need to live in the plan’s service area. There is no health screening.
Q: When can I buy a Medicare Advantage plan?
A: You can join Medicare Advantage during your initial enrollment period, which is the same seven months surrounding your birthday month. Also, you can join, switch or leave plans every fall between October 15 and December 7, with the new plan starting Jan. 1. 
Q: Can I join a plan if I am under age 65 and starting Medicare for disability?
A: If yes, you may join a Medicare Advantage plan during the seven months surrounding your Medicare effective month. Medicare Advantage plans may decline to cover you if you have End Stage Renal Disease (ESRD). 
Q: How do I join a Medicare Advantage plan?
A: Sign up first for Original Medicare with Social Security. Then join the Medicare Advantage plan:
  • By speaking with one of our licensed agents at (920) 858-8752

 or

Q: Why would I join a Medicare Advantage plan instead of staying in Original Medicare?
A: This is a very personal decision and people may make it for a variety of reasons. Some reasons we have heard from clients include: 
For greater provider access in some areas of the state. Some counties have few providers willing to take new Medicare patients, or patients with both Medicare and Medicaid. In some cases, people find they have better provider access with a Medicare Advantage plan that has a network of providers. 
No health screening. Some people, especially those with disabilities who are under age 65, may not qualify for a Medigap/Medicare Supplement plan due to their health. Unless people have End Stage Renal Disease, they can join a Medicare Advantage plan regardless of health. 
Q: Why would I stay in Original Medicare with a Medigap instead of joining Medicare Advantage?
A: This is a very personal decision. Some reasons we have heard from clients include: 
  • Peace of mind paying a flat rate for a premium to have lower or no out-of-pocket costs and balances when you get care. 
  • Ability to travel in the U.S. without worrying if you are in a plan’s service area. 
  • Freedom to choose providers with no referrals required. 
Q: Are you leaving a Medigap plan?
A: If you change from a Medigap to a Medicare Advantage plan or other replacement plan, its up to you to cancel your Medigap/Medicare Supplement coverage. 
If you paid a yearly premium for your Medigap plan, the law does not require the plan to refund you any portion of that premium. Do not cancel your old plan until you verify you are active in your new coverage. 

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© 2021 UpgradeMyMedicare. All rights reserved. UpgradeMyMedicare is a trademark of Allboc Insurance Solutions, LLC

Allboc Insurance Solutions, LLC is a licensed and certified representative of a Medicare Advantage (HMO, PPO, and PFFS) organization and a stand-alone prescription drug plan with a Medicare contract. Enrollment in any plan depends on contract renewal. By completing the contact form above or calling the number listed above, you will be directed to a licensed sales agent who can answer your questions and provide information about Medicare Advantage, Part D or Medicare supplement insurance plans. Availability of carriers and products are dependent on your resident zip code.

The purpose of this communication is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. Medicare Supplement insurance is available to those age 65 and older enrolled in Medicare Parts A and B and in some states to those under age 65 eligible for Medicare due to disability or End Stage Renal disease. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.

For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-833-274-9944, 24 hours a day/7 days a week or consult www.medicare.gov.

*Allboc Insurance Solutions and UpgradeMyMedicare are not affiliated with any governmental program or agency. Plans can only be changed during certain times of the year.

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