No one plan fits all. Not all plans or carriers are the right choice. We help the client choose the right plan.
Medicare Advantage Plans, or Part C, are plans offered by private health insurance companies that are approved by the Centers for Medicare and Medicaid Services (CMS). These plans were created by Congress and signed into law in 1977, by President Bill Clinton, primarily for the purpose of creating a lower cost alternative to purchasing a Medicare Supplement. Medicare Advantage Plans have the following features:
- The plans take over primary coverage from Original Medicare Part A and B and provide a low or no share of cost with a maximum out of pocket cap of large medical expenses.
- You are guaranteed to have the coverage upon enrollment. The only exception is if you have End-Stage Renal Disease (ESRD).
- You can enroll at various enrollment periods, unlike Medicare Supplement Plans where you only have one general Guaranteed Issue period.
How Does a Medicare Advantage Plan Work?
Insurance companies that offer these plans are paid an ongoing fee per enrollment by the Centers for Medicare and Medicaid Service. Because of this, most clients pay no premiums or, with some plans and some locations, a small premium. In order to enroll in this plan, you must currently be enrolled in Original Medicare Part A and B.
When visiting your doctor, you show only your Medicare Advantage Card and do not need to show your Original Medicare Card. Medicare Advantage Plans have a network of providers you must see to get benefits. About 71% of plans countrywide are HMOs. These are the type of plans that require you to choose a Primary Care Physician who will coordinate all your healthcare. There are other types of plans offered such as PPO, Private Fee For Service Plans, or Medicare Savings Account Plans, however, the availability of these plans vary based on what county you live in.
Many plans also include Prescription Drug Plans which are part of the zero premium coverage that is included in the Medicare Advantage Plan. In addition to the core health benefits, there are ancillary benefits either as a buy-up option or embedded in the plan. These benefits include but are not limited to:
- Dental: Full comprehensive coverage
- Vision: Exam, lenses, and an allowance for frames or contact lenses
- Hearing: Exam and a hearing aid allowance
- Transportation: Limited to going to your doctor or pharmacy
- Gym membership.
The enrollment periods are as follows:
- Initial Coverage Election Period (ICEP). This is a one-time event when you can enroll for a Medicare Advantage Plan for the first time. It is typically when you are newly eligible for and are enrolled in Original Medicare Part A and Part B. This period includes the 3 months prior to your eligibility for Original Medicare, the month you are eligible, and the 3 months after you become eligible and enroll in Original Medicare, for a total of 7 months
- Annual Election Period (AEP). This period occurs every year from October 15 to December 7. During this period, you can switch from one Medicare Advantage Plan to another or drop your Plan and go back to Original Medicare. It would be advisable to enroll in a standalone Prescription Drug Plan since Original Medicare does not cover Prescription Drugs. You may enroll in a Medicare Supplement plan if you drop your Medicare Advantage Plan, but you may be subjected to medical underwriting. The effective date of your change will be January 1 of the following year.
- Special Election Period (SEP). This enrollment period is utilized when there is no other enrollment period to use. Centers for Medicare and Medicaid formulated the events that qualify and are uniform across the different insurers. The effective date of your enrollment will be the 1st of the month following the date of enrollment. There are 2 common qualifying events that allow enrollment anytime during the year. They are
- Chronic conditions such as cardiovascular, pulmonary, or diabetic conditions. One SEP is allowed anytime during the year to enroll, change, or drop your Medicare Advantage Plan.
- Dual Eligible or Medi-Medi qualification. Having full Medi-Cal allows enrollment into or change to a different Medicare Advantage plan. This can occur once a quarter for the first 3 quarters of the year.
- Medicare Open Enrollment Period (OEP). OEP occurs from January 1stthrough March 31stof each year. You can drop your Medicare Advantage plan and go back to Original Medicare at which point you can sign up for a standalone Part D prescription drug plan. As of 2019, you can switch your Medicare Advantage plan to a different one. This period does not allow you to sign up for a plan unless you are already enrolled in one.
- General Enrollment Period begins on Jan 1 and ends on March 31. This period is for signing up for Original Medicare Part B if you did not sign up during your Initial Enrollment Period. The effective date for Part B during this period is July 1.
Medicare Advantage Rules
- You must be enrolled in Original Medicare Part A AND Part B. If Part B is dropped you will be disenrolled from your Medicare Advantage Plan.
- You cannot enroll in a Medicare Advantage Plan if you are diagnosed with End-Stage Renal Disease or kidney failure.
- In general, you must use in-network providers or your medical services will not be covered. The only exception is in life threatening emergencies. Also, if you are in an HMO Plan, you must get prior authorization to see a specialist and to have certain procedures done.
Other Considerations About Medicare Advantage
- Advantage plan benefits may change every year. It is a good idea to reevaluate your coverage during AEP to make sure you have the best benefits available for the following year. Your enrollment is generally for the entire year. You have to actively disenroll from a plan you don’t want by either contacting the insurance company or, if you qualify for a particular enrollment period, enroll in another MAPD or Part D plan. This will automatically disenroll you from your current MAPD plan.
- Make sure you want this coverage long term if you enroll at age 65. Your initial enrollment period for Medicare Supplement occurs roughly the same period. When you miss this period, which is also the Guaranteed Issue period, you can be turned down for a Medicare Supplement plan if you decide to enroll outside this period and are not healthy enough to qualify.
We often are asked our opinion on which plan is the best Medicare Advantage plan. This varies based on a number of personal factors. What’s right for your friend or neighbor may not be right for you. Don’t risk making a mistake on something as critical as your health insurance. Call Halili Hilltop at 562-343-7301. As Medicare broker/consultants we can help you choose the right plan for your circumstance.
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