What Are Medicare Advantage Plans?
Medicare Advantage Plans are a privatized form of health insurance that can be used to cover all of your Original Medicare benefits. Additionally, these plans may cover other services that are not part of your Original Medicare Plan.
Medicare Advantage Plans, also known as Medicare Part C, combine all the benefits of Medicare Parts A and B. However, unlike Parts A and B, Medicare Advantage may offer additional coverage, such as prescription drug costs. These plans are offered through private insurers who have been approved and authorized by Medicare.
Who Qualifies for Medicare Advantage Plans?
In order to qualify for Medicare Advantage Plans, you must meet all of the following three conditions:
- You are already enrolled in Medicare Parts A and B
- You don't suffer from End-Stage Renal Disease (ESRD)
- You must live in the service area of your plan of choice
Individuals who meet the above three requirements typically qualify to enroll in Medicare Advantage Plans.
What Types of Medicare Advantage Plans Are Available?
Medicare Advantage Plans come in a variety of forms. Typically, individuals can qualify for the following types of Medicare Advantage Plans:
- Private Fee-for Service (PFFS)
- Preferred Provider Organization (PPO)
- Medical Savings Account (MSA) Plan
- Health Maintenance Organization (HMO)
This provides greater flexibility for individuals looking to enroll in a Medicare Advantage Plan.
Good to know:
Discuss health plans options with your doctor. Go over your insurance company's list of covered prescription medications with your doctor. Some medicines will cost you more than others. If your doctor knows what's on your insurer's list, he can select the best medication for you at the lowest price. Also, if your plan requires you to get a referral to a specialist, take your insurance plan's preferred-provider list to your primary-care appointment. Your doctor can easily pick out the best specialist who participates in your plan.
Why Have Medicare Advantage Plans Risen in Popularity?
Medicare Advantage Plans have become a popular form of healthcare coverage for millions of Americans.
The popularity of Medicare Advantage Plans can be traced to the many benefits they offer to consumers—most notably, in terms of lower price and better coverage.
Generally speaking, many consumers find that Medicare Advantage Plans offer the same benefits as Medicare Parts A and B for a lower rate. Additionally, depending on the plans chosen, enrollees may enjoy additional coverage not covered under their original Medicare plans.
The different types of Medicare Advantage Plans have worked to bring more consumer choice into the market. By and large, the majority of Medicare Advantage enrollees have chosen HMO plans, while many others sign up for PPO options.
Additionally, many enrollees find that Medical Advantage Plans tend to lower their overall medical costs. This can be done through lower copays, deductibles, and premiums—when compared to being part of Original Medicare alone.
The privatization of Medicare Advantage Plans also works to provide a number of benefits to enrollees. Typically, this can be seen in terms of consumer choice, where individuals have greater control over the coverage they receive. This can serve to reduce overall costs while still providing enrollees with the coverage they need. Additionally, because these plans are privatized, many consumers find that they offer greater customer support, making it easier to address any concerns they may have about their coverage.
Finally, because most Medicare Advantage Plans cover prescription drug costs, consumers have begun to favor them.
With the price of prescription drugs on the rise, consumers now favor plans that can help cut the cost of their prescription medication. As Original Medicare Plans do not cover
prescription drug costs, Medicare Advantage has become an increasingly-attractive option for millions of consumers.
What Do Medicare Advantage Plans Cover?
Before investing in a Medicare Advantage Plan, make sure to know just what they cover. Fortunately, these plans offer far-reaching coverage that prove beneficial to a number of consumers.
Of note, Medicare Advantage Plans must cover everything that Original Medicare does. Additionally, Medicare Advantage Plans will cover any costs that are associated with emergency room or urgent care visits.
Keep in mind, however, that some of your coverage may depend on the provider you choose. Medicare Advantage Plan providers are not required to cover any procedure they deem not to be medically necessary. For this reason, be sure to check with your potential plan provider for more specific information on what services may or may not be covered.
Some Medicare Advantage Plans may offer additional benefits. These plans include services such as:
- Health and Wellness Programs
If you're interested in these additional services, be sure to discuss them with your Medicare Advantage Plan provider. By not discussing the details of your Medicare Advantage Plan in advance, you may miss out on additional coverage. Many individuals remain unaware that some forms of additional coverage will only be offered if requested; additionally, plan providers must provide you with a written response to your request for additional coverage if they choose to deny it.
Known as "organization determination," this process allows consumers to have greater transparency in choosing their Medicare Advantage Plans. It also provides a greater security net for consumers, as providers that fail to properly execute the organization determination process may be subject to covering additional charges.
These specific incidents occur when your provider fails to provide you with an organization determination and one of the following situations occurs:
- You're referred to an out-of-network provider to have work done when these services would have been covered under your plan in your network, and
- You've been referred to have services done that you could have reasonably expected to have been covered under your plan.
Good to know: Just because your doctor writes you a prescription doesn't mean you can fill it. Expensive medications for treatment of certain cancers, diabetes, liver disease, and a host of other maladies can cost patients tens to hundreds of thousands of dollars if the insurer does not cover the drugs. But even if the drugs are covered, insurers have been known to try to stall, just to see if the patient will come up with the money to pay for the drugs rather than wait on the insurer's approval. What can we say? It happens.
In these incidents, individuals not provided with an organization determination may be subject to paying only their plan's usual cost-sharing price for any services rendered.
Additionally, Medicare Advantage Plans offer other safeguards to protect consumers from wrongfully paying for services. If, for example, you have been made to pay out-of-pocket for a service that was deemed "medically unnecessary," you have the right to appeal your decision. If you can prove the medical necessity of your case, you may be entitled to financial compensation.
Importantly, you can make these appeals prior to and even after the services have been rendered. In the former case, you can attempt to secure coverage for your procedure, and in the latter, you can try to secure reimbursement for the cost of your treatment.
Keep in mind that this appeals process has five levels, meaning that you can appeal the decision of your appeal if necessary.
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