As I said before, Part C or Medicare Advantage or MA, is at it's most basic structure a replacement for Original Medicare Part A and B. It is a type of Medicare health plan offered by a private insurance company that contracts with Medicare to provide you with all your Part A and Part B benefits.
It is not offered, like A and B, directly by the federal government but rather through many different private insurance companies across the states. Some of these insurance companies are nationally known companies while others are more local to a region or even a state.
All of these plans are reviewed and authorized by the CMS. They must all conform to certain minimal requirements that form the basis for the replacement of A and B. They also have to be reviewed and authorized to operate by individual state authorities in every state they want to market in.
If these plans pass all of these conditions they contract with Medicare to supply services enumerated in their plans.
If you join a Medicare Advantage Plan, you still have Medicare. You'll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare.
When you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare, rather they are paid by the insurance company.
Medicare Advantage Plans may also offer extra coverages not available in Original Medicare.
Ther are different "flavors" of Advantage plans and all of them may not be offered in your State and/or County (or other political divisions within a state like parishes and boroughs).
Among the different types of MA plans available are:
- Health Maintenance Organization (HMO) Plans
- Preferred Provider Organization (PPO) Plans
- Private Fee-for-Service (PFFS) Plans
- Special Needs Plans (SNPs)
- HMO Point of Service (HMOPOS) Plans
- Medical Savings Account (MSA) Plans
I'll go into the specfics of these types of plans in later posts, but for know I'll cover some common characteristics of MA plans.
Medicare pays a fixed amount for your care each month to the company offering your MA Plan. The insurance company must follow rules set by Medicare.
However, each MA Plan can charge different out-of-pocket costs. Each plan can also have different rules for how you get services, like whether you need a referral from a primary care physician (PCP), sometimes called a "gate-keeper", to see a specialist. You most likely have to go to doctors, facilities, or suppliers that belong to the plan's network for non-emergency or non-urgent care
Plan networks are usually confined to specific areas or regions and may not include all doctors or hospitals or labs in those areas. For these networks the insurance company has contracted with each supplier of services to join their network. These networks can change each year.
You usually get some prescription drug coverage (Part D or PDP) through the plan. You can join a separate Medicare Prescription Drug Plan (PDP) with certain types of plans that:
- Can’t offer drug coverage (like Medicare Medical Savings Account plans)
- Choose not to offer drug coverage (like some Private Fee-for-Service plans)
If you’re in a MA HMO or PPO, and you join a separate Medicare Prescription Drug Plan, you’ll be disenrolled from your MA Plan and returned to Original Medicare.
Your out-of-pocket costs (OOP or MOOP) (premiums, copays, deductibles, etc.) in a MA Plan depend on:
- Whether the plan charges you a monthly premium in addition to your Part B premium.
- Whether the plan pays any of your monthly Part B premium.
- Whether the plan has a yearly deductible or any additional deductibles.
- How much you pay for each visit or service (copayment or coinsurance). For example, the plan may charge a copayment, like $10 or $20 every time you see a doctor. These amounts can be different from plan to plan.
- The type of health care services you need and how often you get them.
- Whether you go to a doctor or supplier who accepts Medicare assignment rules (if you're in a PPO, PFFS, or MSA plan and you go out-of-network).
- Whether you follow the plan's rules, like using network providers.
- Whether you need extra benefits and if the plan charges for it.
- The plan's yearly limit on your out-of-pocket (MOOP) costs for all medical services.
- Whether you have Medicaid or get help from your state.
Each year, plans establish the amounts they charge for premiums, deductibles, and services. The plan (rather than Medicare) decides how much you pay for the covered services you get. What you pay the plan is allowed to change only once a year, on January 1.
We'll get into the details of each type of plan, typical coverages, additional coverages they may offer and even some "typical" costs, in later postings.