Most Americans, upon reaching the age of 65, will become eligible for Medicare. Through this program, participants receive coverage that helps them pay for hospital visits, doctors’ services, and other health care needs. While Medicare does not provide care directly to enrollees, it does offer reimbursement to providers and/or participants for the cost of certain health care services and procedures.
There are four parts to Medicare coverage. These include:
Medicare Part C is also referred to as Medicare Advantage. These plans can be purchased through private insurance companies that are approved by Medicare. Most Medicare Advantage plans are operated as managed care plans. This means that they work in a similar fashion to HMOs (Health Maintenance Organizations) or PPOs (Preferred Provider Organizations).
The Medicare Advantage plans that are offered are required to provide the same benefits and services as “Original Medicare” (Medicare Parts A and B). Therefore, an individual who is enrolled in a Medicare Advantage plan will not also need to be enrolled in Medicare Part A or Part B.
When an individual joins a Medicare Advantage plan, they will be provided with all of their Medicare Part A and Part B coverage – as well as other services such as emergency and urgent care coverage. Medicare Advantage plans will also typically provide other additional benefits over those provided by Original Medicare. These may include dental, vision, and/or wellness programs.
Because these plans are offered by private insurers, each Medicare Advantage plan may have different rules for how their enrollees may obtain services, such as requiring a referral in order to see a specialist. Additionally, plan providers may change their coverage rules each year.
Those who are enrolled in a Medicare Advantage plan still technically have Medicare. The difference is that these individuals simply get their Medicare Part A (hospital coverage) and Medicare Part B (doctors’ services) from the Medicare Advantage plan and not from Original Medicare.
Because Medicare Advantage plans can offer a number of different options, they may be more directly suited to a participant’s specific health care needs. And, while there may be certain rules for obtaining coverage via a Medicare Advantage plan as versus Original Medicare, the premiums and/or the cost of services such as copayments are often lower with a Medicare Advantage plan versus Medicare Parts A and B.
There are several different types of Medicare Advantage plans, and each differs somewhat in the way that services are offered and obtained. These plans include:
In addition, Medicare Advantage also offers some less common plan options, including:
In most cases, an enrollee in a Medicare Advantage plan will have prescription drug coverage (Medicare Part D) included directly through the plan. However, there are some Medicare Advantage plans that do not include coverage for prescription drugs. In these cases, an individual would need to purchase a separate Medicare Part D prescription drug plan if they want such coverage.
It is important to note, however, that an individual cannot be enrolled in both Medicare Advantage and a Medicare Part D prescription drug plan. Therefore, if an individual wishes to enroll in Medicare Part D, then he or she will need to obtain their Medicare coverage via Original Medicare (Medicare Parts A and B).
Medicare supplement insurance offers benefits that are designed to fill in the “gaps” in Medicare Part A and B coverage such as out-of-pocket copayments and deductibles. These plans are only supplemental to what Original Medicare covers. Therefore, these plans do not provide coverage for services that are not already covered by Medicare Part A or B such as non-essential cosmetic surgery.
A Medicare supplement policy may be purchased through a private insurer that offers such coverage. There are a number of different Medicare Supplement plan options to choose from, and all correspond to a letter of the alphabet – with Plan A offering the most basic set of benefits.
Because Medicare Supplement insurance works in conjunction with the coverage gaps that are left by Medicare Parts A and B, it is not necessary for an individual who has Medicare Advantage to also have coverage through a Medicare Supplement insurance policy.
Due to the fact that Medicare Advantage plans are offered through different companies and in different demographic areas, the premium for this type of coverage will differ among plans. In addition, each Medicare Advantage plan may also charge different out-of-pocket costs to enrollees.
In order to qualify for a Medicare Advantage plan, an individual must meet certain criteria, including:
In order to enroll in a Medicare Advantage plan, individuals must do so within certain time frames called enrollment periods. The most common time for someone to enroll in Medicare Advantage is three months prior to his or her 65th birthday.
Some individuals under age 65 receive Medicare due to disability. They may be able to enroll in a Medicare Advantage plan either during the three months prior to or the three months following the 25th month of the onset of the disability.
For those who are already enrolled in Medicare Advantage and want to switch to a different Medicare Advantage plan, it is possible to simply join the new plan during one of the open enrollment periods.
When the coverage from the new Medicare Advantage plan begins, individuals will automatically be removed from their previous plan. Those who wish to leave their Medicare Advantage plan in order to switch back to Original Medicare should contact Medicare directly in order to do so.
Once an individual has decided on a Medicare Advantage plan to join, the following steps will be necessary in order to enroll:
In order to purchase a Medicare Advantage plan, it will be necessary to provide the insurer with your current Medicare identification number, as well as the date that your Medicare Part A and/or your Medicare Part B began. All of this information may be located on your Medicare identification card.
By Susan Wright
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Downtown Bellevue, just off I-405