Medicare Advantage Coverage
Medicare Advantage coverage varies greatly by location. Some areas have $0 Medicare Advantage (MA) plans; however, other areas have higher premium plans available.
Advantage plans offer coverage on things like routine vision, dental, hearing as well as Part D medications. Silver Sneakers is available on MA plans in certain areas; also, those with this benefit will have access at dedicated gym locations.
MA plans are required to cover at least as much as Original Medicare; although, most policies offer far better coverage than Medicare alone.
Medicare Advantage Coverage
Part C plans are Medicare Advantage plans, these plans are offered by private insurance companies to provide you with coverage. However, each plan can have a different network of providers, coverage rules, premiums, and cost-sharing amounts for covered services.
Medicare Advantage eligibility is simple; you must have Original Medicare, live in the plan service area, and not have End-Stage Renal Disease (ESRD).
Although, in some areas, Medicare Advantage Special Needs Plans (SNP) are available to those with ESRD that need dialysis or a kidney transplant.
However, depending on the type of MA plan you select, you may have to stay with in-network providers.
Types of MA Plans
An HMO plan is a Health Maintenance Organization; this type of MA plan requires referrals and the use of in-network doctors. Although, if you leave the network, you can be responsible for 100% of the healthcare costs.
PPO stands for Preferred Provider Organization; with this policy, out of network providers can be used if you pay the higher rates. However, going out of network frequently can cause your health care expenses to be outrageous.
The HMO-POS plan can provide beneficiaries with a more flexible HMO network. Under some situations, you can see an out of network provider for certain treatments. Although, leaving the networks can cost more, and some plans still require referrals.
Only certain areas offer Private Fee for Service (PFFS) plans to beneficiaries; with this plan, you don’t need to pick a primary care provider or receive a referral. However, you must verify that the doctor will accept Medicare’s rules before each visit.
Medical Savings Accounts (MSA) is the Medicare equivalent of a health savings account. This type of policy may not be available in your area. These plans don’t include prescriptions; so, you’ll need to enroll in a stand-alone Part D policy.
MA with Part D
The Majority of Medicare Advantage plans include Part D coverage; however, not every plan includes this benefit.
For the most part, you can’t have an MA plan with a separate Part D plan. However, this isn’t always the case; PFFS plans that don’t have Part D coverage can be paired with stand-alone Part D coverage.
Each MA plan has a formulary or a list of covered drugs. Before enrolling, check that all your drugs are covered. Drugs will cost differently based on the tier the medication is listed; for example, generic drugs will cost less than specialty drugs.
Two different plans could cover the same prescription at a different cost to you, researching your plan options will save you money. Formularies change each year, double checking your prescriptions annually is highly recommended.
Out of State with MA
Most Medicare Advantage plans only cover beneficiaries inside the coverage area. However, if you’re leaving the plan’s service the area, contact the plan to understand your coverage.
For the most part, when you’re traveling out of state you can’t receive non-emergency care. However, depending on your plan rules, you could just pay a higher fee for using an out of network provider.
If you’re looking to travel during your retirement, most Medicare Supplements will provide you with nationwide coverage and foreign travel emergency care.
Medicare Advantage and Employer
Having small employer group coverage means Medicare is primary; some seniors in this situation benefit more from taking Medicare and dropping the employer coverage. A small employer is less than 20 employees.
If you work at a larger company, Medicare is secondary. You should talk with your benefits administrator about your Medicare options. Although, most seniors take premium-free Part A and postpone Part B enrollment.
Some Employers offer retires Medicare Advantage coverage, this isn’t always the case and comparing plans in your area is still encouraged.
If you have employer coverage that is an HSA, don’t enroll in Original Medicare. You can’t contribute to a Health Savings Account if you have any form of Medicare.
Most Medicare Advantage plans operate like Employer plans; however, if you have primary employer coverage, it might not benefit you to choose Medicare. Talk with your benefits administrator about the best choices in your area.
Medicare Advantage Claims
Opting for a Medicare Advantage plan means Medicare no longer determines coverage for services. Also, the Medicare Advantage policy will pay the claims, not Medicare.
Medicare Advantage plans have limitations in place. Prior authorization requirements can create barriers for patients that need timely access to care.
With a Medicare Supplement, when Medicare approves the service, the supplement MUST also approve the service.
Medicare Advantage plan applications can be over the phone. Although, it’s important to understand any limitations associated with potential coverage.
Having Medigap coverage will give you peace of mind as your health deteriorates. Additionally, Medigap allows you to see any doctor in the United States that accepts Medicare, without a referral.
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