Medicare advantage FAQ

What is Medicare Advantage or Medicare Part C?

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 Medicare Advantage, sometimes referred to as Medicare Part C, is the option within Medicare that allows beneficiaries to enroll in a healthcare plan offered through private companies. If you join a Medicare Advantage Plan, you still have Medicare. You will receive your Medicare Part A and Medicare Part B coverage from the Medicare Advantage Plan, instead of through traditional Medicare. Under traditional Medicare, the government pays for your Medicare benefits when you are eligible to receive them. Under Medicare Advantage Plans, Medicare pays private companies a set amount per person per month to cover your benefits.  

If I’m in a Medicare Advantage plan, will I receive Part A and B benefits? Will I receive Part D?

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 Medicare Advantage plans are required to cover all Parts A and B benefits provided under traditional Medicare. Medicare Advantage is not required to cover Part D benefits. However, approximately 90% of Medicare Advantage plans offer Part D prescription drug coverage that you may select from. 

What is the difference between traditional Medicare and Medicare Advantage?

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 Traditional Medicare includes Part A (hospital) and Part B (medical) coverage, if you enroll in both. Most people pay a monthly, income-based premium for Medicare Part B. Traditional Medicare does not cover visual, hearing, and dental benefits, and there is no limit on yearly amounts of out-of-pocket care costs. Under Traditional Medicare, you can go to any doctor or hospital in the United States that accepts Medicare. If you want Medicare drug coverage (Part D), you must purchase a separate Prescription Drug Plan (PDP) from a private insurance company. If you have traditional Medicare, you may also choose to purchase a supplemental insurance policy to cover out-of-pocket physician costs called Medigap. Under Medicare Advantage, you still pay Part B premiums. However, over 97% of Medicare Advantage plans offer at least a vision, hearing, or dental benefit, and half of Medicare Advantage plans offer all three benefits. Medicare Advantage Plans does have yearly limits on your out-of-pocket health care costs. Once you reach your maximum out-of-pocket spending, you pay nothing. The most common types of Medicare Advantage Plans are HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations). Under Medicare Advantage, the providers you can visit depend on the type of plan you select. This is referred to as the “provider network” and plans offer information on which providers are in their plan. If  you want a plan that includes Medicare drug coverage (Part D), you can sign up for a Medicare Advantage Prescription Drug Plan (MA-PD) which includes both health and drug coverage. 

What are the plan types under Medicare Advantage?

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 Medicare Advantage offers the following types of plans: 

  • Health Maintenance Organization (HMO): In most HMOs, you can only go to doctors, other health care providers, or hospitals in the plan’s network, except in an urgent or emergency situation. You may also need to get a referral from your primary care doctor for tests or to see other doctors or specialists. • 
  • Preferred Provider Organization (PPO): In a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You usually pay more if you use doctors, hospitals, and providers outside of the network. • Private Fee-for-Service (PFFS): PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they accept the plan’s payment terms. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care. 
  • Special Needs Plan (SNP): SNPs provide focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions. 
  • Health Maintenance Organization Point-of-Service (HMO-POS): These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. 
  • Medical Savings Account (MSA): These plans combine a high-deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year. MSA plans don’t offer Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan. 

To research plans and determine which plan may be right for you, schedule an appointment at our agency. 

What are the Medicare Advantage eligibility requirements?

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 If you are eligible for traditional Medicare, you generally are eligible to choose a Medicare Advantage page. To be eligible for a Medicare Advantage plan, you must be enrolled in Medicare Parts A and B, and live in the Medicare Advantage service area. You can join a Medicare Advantage plan even if you have a pre-existing condition, except for End-Stage Renal Disease (ESRD) (dialysis patients). There are also other special circumstances under which you can enroll in a Medicare Advantage plan. The chance to enroll or change plans occurs when you first become eligible for Medicare, or once a year between October 15 – December 7. 

Under what special circumstances can I sign up for Medicare Advantage outside of open enrollment?

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 There are special circumstances when individuals can sign up for Medicare Advantage outside of the open enrollment period including if: • You find out that you will not be eligible for Extra Help for the following year.  » Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance. • You retire from your employer or union and have an employer sponsored retiree plan. • You drop your coverage in a Program of All-inclusive Care for the Elderly (PACE) plan.