Medicare Advantage Coverage
Medicare Advantage coverage varies mostly by location. Some areas have $0 Medicare Advantage plans, whereas other areas may have higher premium options.
Advantage plans offer coverage on things like routine vision, dental, hearing. Also, some Medicare Advantage plans include coverage for Part D.
Then, some insurers provide the Silver Sneakers program; this program allows seniors access to gyms and classes.
Advantage plans must cover at least as much as Medicare; although, most policies offer more benefits than Medicare coverage.
Medicare Advantage Coverage
Part C is a Medicare Advantage plan; these plans come from private insurance companies to provide you with coverage. However, each program can have a different network of providers, coverage rules, premiums, and cost-sharing amounts for services.
Advantage eligibility is simple; you must have Medicare, live in the plan service area, and not have End-Stage Renal Disease (ESRD). Although, in some regions, Medicare Advantage Special Needs Plans (SNP) are available to those with ESRD that need dialysis or a kidney transplant.
However, if you select an HMO Medicare Advantage plan, you may have to stay with in-network providers. While HMO’s have limits on the doctor network, many plans coming out in 2020 have more extensive networks than ever before.
More coverage options at lower costs are the goal for Medicare Advantage in 2020.
Types of Medicare Advantage Plans
An HMO plan is a Health Maintenance Organization; this type of Medicare Advantage 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 the 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 specific treatments. Although leaving the network 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.
Medicare Advantage with Part D
The Majority of Medicare Advantage plans include Part D coverage; however, not every program consists of this benefit.
For the most part, you can’t have a Medicare Advantage plan with a separate Part D plan. However, this isn’t always the case; PFFS ideas that don’t have Part D coverage can be paired with stand-alone Part D coverage.
Each Medicare Advantage 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 separate cost to you, researching your plan options will save you money. Formularies change each year; double-checking your drugs annually is highly recommended.
Out of State with Medicare Advantage
Most Advantage plans only cover beneficiaries inside the coverage area. However, if you’re leaving the plan’s service the area, contact the company 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 pay a higher fee for using an out of network provider.
If you’re looking to travel during your retirement, most supplements 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 to your benefits administrator about your options. Although, most seniors take premium-free Part A and postpone Part B enrollment.
Some Employers offer retiree Medicare Advantage coverage, this isn’t always the case and comparing plans in your area is still relevant.
If you have employer coverage that is an HSA, don’t enroll in Medicare. You can’t contribute to a Health Savings Account if you have any form of Medicare.
Most 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 allow the service.
Medicare Advantage plan applications can be over the phone. Although, it’s essential to understand any limitations 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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