Medicare Advantage

Making the right choice in Medicare advantage plans
by Pat Venable, SHIP Coordinator, Baltimore County Department of Aging.

Congress created Medicare Advantage Plans to let more private insurance companies offer coverage to people with Medicare, giving them more choices in how to get their Medicare benefits. If people join one of these plans, they generally get all their Medicare-covered health care through that plan and the plan may offer extra benefits that Medicare doesn't cover, such as vision or dental services. Medicare pays a set amount of money for a personal care every month to these private health plans, whether or not the member uses services.

People must have both Medicare Part A and Part B and must live in the plan's geographic service area to join a Medicare Advantage Plan. They may pay an additional monthly premium to the plan and they will have to pay other costs (such as co-payments) for the services they get. The plan may also have special rules that its members need to follow.

In some plans, like Medicare Health Maintenance Organizations (HMOs), people may only be able to see certain doctors or go to certain hospitals. However, members have the right to get emergency care anywhere in the United States when they need it without any prior approval from the plan. Since each plan can vary, it's important that people review plan materials carefully for details about co-payment and coverage information.

When comparing Original Medicare and joining a Medicare Advantage Plan, a person must make sure they know all the costs and co-pays. Original Medicare has deductibles and usually only pays 80 percent of the cost. A person needs to supplement Medicare with a Medigap Policy, Medicare Advantage Plan, Group Retirement Plan, TriCare, or Medicaid. It is also important to be sure a person can pay the monthly premiums, co-pays and deductibles.

If a person stays in Original Medicare, they have coverage nationwide and many doctors and hospitals accept Medicare. Medicare Advantage members need to stay in their networks except in emergencies or pay more money. If a person is on Medicaid, some states do not pay the co-payments for Medicare Advantage Plans.

Medicare Advantage Plans in your area are listed in the back of the Medicare and You 2008 book. There will be salespeople marketing these plans for open enrollment from November 17 to December 31 and January 1 to March 31.

Medicare Advantage Plans can be sold all year long to people in the Medicare Savings Programs and people new to Medicare. It is important to review the co-payments and premium costs for the plan before you enroll.

If a person joins a Medicare Advantage Plan, they will still be in Medicare but need to get all their services through the MA plan. If you want to join a plan but need to change doctors, you need to make sure a doctor in your neighborhood who is participating in the plan is accepting new patients before you enroll.

Remember, Medicare pays a set amount of money for personal care every month to these private health plans, whether or not the member uses services. Original Medicare will no longer accept bills from providers for Medicare services.

There are special trial rights available for people who have joined a Medicare Advantage plan for the first time. They can drop their MA plan and enroll in the Original Medicare Plan anytime within the first 12 months of their Medicare Advantage plan coverage.

People are eligible for this trial right if they either joined an MA plan when first eligible for Medicare at age 65, or were in the Original Medicare Plan, enrolled in a MA plan for the first time, and dropped a Medigap policy. The trial right allows them to disenroll from the MA plan during the first 12 months and return to Original Medicare and their Medigap policy.

People new to Medicare also have a guaranteed issue opportunity to purchase a Medigap (Medicare supplement) policy.

Five main types of Medicare Advantage Plans

Medicare Health Maintenance Organizations (HMO)
HMO plans cover all Part A and B services and may provide extra services. You can generally only go to doctors, specialists, or hospitals that are part of the plans network, except in an emergency. People who join a Medicare HMO Plan may be asked to choose a primary care doctor in the network. The primary care doctor is the doctor they see first for most health problems and will give referrals to see a specialist (such as a cardiologist) or to get certain services.

Medicare Preferred Provider Organization (PPO)
This plan is similar to an HMO plan, but members in a Medicare PPO generally can see any doctor or provider that accepts Medicare. They don't need a referral to see a specialist. The plan has a network of preferred doctors and specialists. If members go to doctors, hospitals, or other providers that aren't part of the plan (out-of-network or non-preferred), they don't need a referral, but they will usually pay more.

Medicare Special Needs Plans (SNP)
Membership in a SNP is limited to certain groups of people, such as those with certain chronic or disabling conditions or in some institutions like a nursing home. Medicare Special Needs Plans are Medicare Advantage Plans designed to provide focused care management, special expertise of the plans providers, and benefits tailored to enrollee conditions. These plans provide case management, care monitoring, health education, and monitoring tools, if needed, to provide specialized care.

Medicare Private Fee-for-Service (PFFS)
This plans members can go to any provider that accepts the plans terms and conditions of payment, and they may get extra benefits. A Private Fee-for-Service plan is a Medicare Advantage Plan offered by a private insurance company under contract to the Medicare program. Some companies may offer more than one plan in an area, with different benefits and costs. The private company decides how much it will pay and how much members pay for services.

Medicare Medical Savings Account (MSA)
MSA plans combine a high deductible Medicare Advantage Plan and a bank account. These Medicare plans are similar to Health Savings Account plans available outside of Medicare, and they have two parts. The first part is a Medicare Advantage Plan with a high deductible. The second part is a Medical Savings Account into which Medicare deposits money that the person with Medicare may use to pay health care costs until the deductible is met. After the deductible is met, Medicare will pay 100 percent of Medicare covered services.

Other Medicare Plans

Three other types of Medicare plans include:

Medicare Cost Plan
Medicare Demonstrations and Pilot Programs
PACE (Programs of All-inclusive Care for the Elderly

*Information compiled by the Baltimore County Department of Aging