Medicare Advantage Plans

Explanation of Medicare Advantage:

Medicare Advantage plans, or Medicare Part “C” plans, are offered by many different insurance companies.  In addition to paying your premium(s) for Medicare parts A & B, depending upon the plan you select, you may also pay a monthly or quarterly premium to the insurance carrier for the Medicare Advantage plans.  You’ll put your red, white and blue Medicare card away, and carry only the ID card for the Medicare Advantage plan when you see your doctor or other provider.

Benefits may be structured as HMO, PPO, PFFS (private fee for service) plans, but the most popular in Northern California are the HMO plans offered by AARP (United HealthCare a.k.a. Secure Horizons, not offered in Santa Cruz or Monterey County), and Health Net (Healthy Heart/Ruby).  These plans combine medical and prescription drug coverage into one plan, simplifying your enrollment.  You may purchase a Medicare Advantage plan (MA) or Medicare Advantage and Prescription Drug plan (MAPD) only during certain enrollment windows in the fall and at the beginning of the year.   Please contact us below for rates in your area.

These plans are regional, so if you move out of state, for example, you may be automatically canceled from your plan but will have a “special” enrollment opportunity to enroll in a new plan offered in your new region, without waiting until the next open enrollment period.

The only enrollment period available for 2014 Part D plans will be the AEP. The AEP begins on October 15 and ends December 7, 2013. After this period, there will be a dis-enrollment period for Medicare Advantage plan members. Advantage plan members who would like to dis-enroll from their plan can do so beginning January 1 through February 14, 2014. If the member chooses to dis-enroll, they will have an opportunity to return to original Medicare and purchase a stand-alone Part D insurance plan. After that period members will be locked into their choice until December 31 of the following year.

Medicare Advantage Details:

HMO plans require that you select a Primary Care Physician and obtain referrals from that physician to any specialist you may wish to see.  Physicians will refer within your medical group, and routine care will not be available if you’re outside of your regular service area.  Emergency care will be provided, but the plan determines what is and is not an emergency.  HMO plans may be best suited to those Medicare Beneficiaries who reside most of the year in their service area and do not travel extensively.  Copayments are charged for office visits, lab work, X-rays, etc. and you may see coinsurance (the plan pays 80% for example, and you pay 20%) for expensive tests, such as MRI or CT Scans.  There may be per-day copayments for hospitalization (i.e. $250/day).

PPO plans provide more flexibility if you travel, as you’re not limited to a single medical group.  Copayments are charged for office visits, and you’ll see a deductible for other services.  These plans cost less each month than the HMO plans, but will cost you more if you need to seek medical attention.  No primary care physician is required.

PFFS plans generally do not have a network of physicians, but each time you receive care, you’ll need to confirm that the doctor, lab, radiology center, etc., will accept the fees paid by the plan.  You may find a doctor willing to work with your plan one day, but may not be willing to accept the plan on another day.  Enrollment in and availability of these plans is declining.

Based on the new Health Care Reform laws, funding for these plans may be decreasing in the coming years. Behind the scenes, if you enroll in MA or MAPD plans, the US government pays a substantial monthly fee to the insurance company, in addition to your payment, in order for the plan to take on the liability of your medical care.  These fees are seen as a potential source of savings to the government, hence the shrinking of enrollment.  Stay tuned for updates……..