Medicare Advantage Insurance
Medicare Advantage Made Easy
Medicare Advantage Insurance
Medicare Advantage Plans look similar to the insurance you had through an employer and are usually offered as HMOs or PPOs. These plans have a set co-pay at your doctor and ER, along with coverage for the hospital, preventive care, and prescription drugs. These plans offer comprehensive coverage (combining your Medicare A, B, and prescription drug benefits into one plan and ID card) that is provided by a private insurance company.
These private insurance companies are paid a fee by the Federal Government to “manage” your Medicare benefits for you. Because these private insurance companies receive funding by our Government, many of them do not charge you any additional premium, besides the current Medicare Part B premium. Some companies charge an additional premium above the Part B amount.
When you enroll in a Medicare Advantage Plan, the company becomes your primary insurance. This policy “replaces” Original Medicare. It does not supplement Medicare. Because of this, you typically have to pay the 20% coinsurance for Part B services like MRIs, Outpatient Surgery, Chemotherapy, and other expenses up to a certain amount each year.
Many Medicare Advantage (Part C) plans include prescription drug, vision, hearing and dental coverage not offered by Original Medicare (Parts A & B). Additionally, each Medicare Advantage plan is required by law to feature an annual maximum cap on out-of-pocket costs, meaning once that limit is reached you will pay nothing for additional covered medical services.
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 the 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 probably 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 generally pay more if you use doctors, hospitals, and providers outside of the network.
Private Fee-for-Service (PFFS) plans: PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as 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.
To be eligible 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) generally cannot enroll in a Medicare Advantage Plan.
You must continue to pay your Part B premium and generally 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 have to cover all of 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.
Like private plans, each has different benefits and rules. Most provide prescription drug coverage; some may require a referral to see a specialist while others won’t. Some may pay some portion of out-of-network care, while others will only cover doctors and facilities that are in the HMO or PPO network.
Remember, plan benefits can change from year to year. Make sure you understand how a plan works before you join.