Medicare Advantage

Medicare Advantage (Part C) is an alternative to Original Medicare. It’s an unusual way to get your Medicare benefits.

By law, every Medicare Advantage plan must include all the benefits provided by Original Medicare (Parts A and B). They may offer additional benefits—and many do. This may include coverage for prescription drugs and for routine dental and eye care, for example. Plans may have provider and pharmacy networks that you need to use.

With a Medicare Advantage plan, you pay a co-pay or co-insurance for health care services you receive. These out-of-pocket costs have an annual cap (no more than $6700 in 2016). Once the limit is reached, your plan pays 100% of your health care costs for the rest of the year. There is no out-of-pocket cap with Original Medicare. In addition, drug coverage is included with most Medicare Advantage plans so there’s no additional premium for it.

You can get your Coppell Texas Medicare benefits through Original Medicare, or you can choose a Medicare Advantage Plan. With Original Medicare, the government pays for your Medicare benefits when you get them. Medicare Advantage Plans are offered by private companies that have been approved by Medicare. Medicare pays these companies to administer your Medicare benefits.

Medicare Advantage Plans combine coverage for the hospital (Part A) and doctor (Part B) visits all in one plan and are required to offer all the benefits included in Original Medicare (except hospice care which continues to be covered by Part A). However, many Medicare Advantage (Part C) plans also include prescription drug coverage and routine eye and dental care coverage not offered by Original Medicare.

If you join a Texas Medicare Advantage Plan, the plan will provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage. They are completely different than a Medicare Supplement Insurance (Medigap) policy.

There are several types of Texas Medicare Advantage Plans:

Health Maintenance Organization (HMO) plans: In most HMOs, you may only go to doctors, other health care providers, or hospitals that are in the plan’s network, except in an emergency or urgent situation. You also need to get a referral from your primary care doctor for diagnostic tests or to see other doctors or specialists.

Preferred Provider Organization (PPO) plans: With a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.

Private Fee-for-Service (PFFS) plans: PFFS plans are like Original Medicare in that you can go to any doctor, other health care provider, or hospital if they agree to accept the plan’s payment terms. The plan will determine how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Special Needs Plans (SNPs): SNPs provide specialized and focused 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.

HMO Point-of-Service (HMOPOS) plans: 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) plans: These plans combine a high-deductible health plan with a bank savings account. Medicare will deposit money into the account (usually less than the deductible). You can use the money to pay for your health care services throughout the year. MSA plans do not offer any Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan, Part C of Medicare.

Medicare Advantage Plans can charge different out-of-pocket costs than Original Medicare and can have different rules about how you get your services. The private insurance companies offering these plans are paid by Medicare a fixed monthly amount. These plans must follow Medicare’s rules and must cover all services that Original Medicare covers; except for hospice which is covered by Original Medicare even if you are in a Medicare Advantage Plan. They may also offer extra coverage such as dental, vision, hearing, and/or wellness benefits and may include Part D. These plans may include cost-sharing such as a monthly premium (in addition to your Part B premium), co-pays, coinsurances, deductibles and are required to have an annual out-of-pocket maximum. Medicare Advantage Plans can change annually, therefore if you have a Medicare Advantage Plan you should review the Evidence of Coverage and Annual Notice of Change sent to you in the fall by your plan. You do not need a Medicare Supplement plan if you have a Medicare Advantage Plan. Medicare Supplements will not cover the deductibles, co-pays, or coinsurances of a Medicare Advantage Plan. To be eligible for a Medicare Advantage Plan you must be enrolled in Part A and Part B, live in the service area of the plan, and not have End Stage Renal Disease (except under specific circumstances).

To be eligible to enroll in a Texas Medicare Advantage plan you must have both Medicare Parts A and B and live in the plan’s service area. People with End-Stage Renal Disease (permanent kidney failure) cannot enroll in a Medicare Advantage Plan.

You must continue to pay your Part B premium and pay one monthly premium for the services included in a Medicare Advantage Plan. Each Medicare Advantage Plan has different premiums and costs for services, so it’s important to compare plans in your area and understand plan costs and benefits before you join. Some may have a $0 premium.

Texas Medicare Advantage Plans must cover all the services that Original Medicare covers except for hospice care. Original Medicare will cover hospice care even if you are in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you will always be covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area (but not outside the U.S.). Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs.

Most Medicare Advantage Plans include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay one monthly premium for both the plan’s medical and prescription drug coverage.

Remember, plan benefits can change from year to year. Make sure you understand how a plan works before you join.