Medicare Advantage Plans
Medicare Part C plans are a fantastic alternative to original Medicare.
Medicare Advantage Plans – Medicare Part C
One of the Medicare options you have that is growing in popularity is the Medicare Advantage Plan, also known as Part C. There is a lot of misinformation about these plans and are too often given a bad reputation by those that simply don’t understand them, or simply can’t sell them.
At Maryland Medicare Options, we are licensed and authorized to sell all types
of Medicare insurance plans including Medicare Advantage Part C plans.
A Part C plan is a great alternative to Original Medicare and typically covers at least what Original Medicare does, plus some great extras. Most plans have prescription drug coverage embedded into the plan, so you don’t have to spend any more on a separate drug plan, and you simply carry around one insurance card rather than two or three.
A Medicare Advantage Plan works differently than Original Medicare. With Part C, the doctors, hospitals and providers work directly with the insurance carriers, determining what they’ll accept as payment towards services. These payments somewhat mirror what Medicare pays, but not always. To better understand how this works, we have to understand why these Advantage Plans exist.
Back in the late 70’s and early 80’s, researchers for the US government were studying the effects that the boomer generation would have on our healthcare system and they were alarmed by the potential underfunding of Medicare. So they set out to design an alternative that would benefit not only the Government, but the consumer and the private healthcare company.
The system they came up with is actually quite brilliant. Normally, the Government would be on the hook for 80% of your medical bills, which can be pretty overwhelming for an underfunded social program like Medicare. So they decided to incentivize you to get off of Original Medicare and move the responsibility over to a healthcare company. The incentive comes in the form of lower monthly out-of-pocket premiums, more benefits and a more streamlined way of getting your insurance.
The Government was able to shift the financial responsibility of paying for your healthcare coverage (the 80%) by offering healthcare companies approximately $1,000 per month for every Medicare recipient that elects to have their Medicare insurance provided by a healthcare company rather than the US Government.
Of course, the healthcare companies can manage $12,000 per year on your behalf much better than the federal government, and they do quite a good job at it. These plans often have many features and benefits that you’d never find over at Original Medicare.
Just some of the benefits you’ll find inside of a Medicare Advantage Part C Plan might be:
- Free Gym membership through Silver Sneakers or Silver & Fit
- Free Transportation to and from plan approved locations (like Dr’s offices / pharmacies)
- Free Over-The-Counter products (quarterly spending limits apply)
- Free Virtual eVisits with physicians (smart phone app required)
- Free Weekly Meals if you qualify
- Free Routine Podiatry / Chiropractic / Vision / Hearing / Acupuncture
- $$$ Towards hearing aids
- $$$ Towards contacts or glasses
- Comprehensive or Routine Dental services
- Personal Emergency Response (PERS) – bracelet / necklace to trigger medical response for falls
- Free Smoking cessation services
- 24 Hour Telephonic Nurse / Doctor helpline
Not all plans will have all of these benefits. Each Advantage plan has its own set of benefits to cater to different clients.
Advantage Plan companies offer a variety of different plans to service many types of consumers. The available Maryland Advantage Plans include:
- MSA – Medicare Saving Account is a very unique Medicare Advantage plan with an investment bank account attached. The company funds the member’s bank account in January and the member uses the money to pay for medical expenses. This is a high-deductible option and not everyone can be approved. MSA plans do not include prescription drug coverage.
- HMO – Health Maintenance Organizations that require you to stay within a network of doctors, hospitals and health centers for non-emergency services. There are no networks for urgently needed or emergency services.
- PPO – Preferred Provider Organizations that require you to stay within a network of doctors, hospitals and health centers but allow you to visit providers outside of the network with different levels of coverage based on the network. There are no networks for urgently needed or emergency services.
- SNP – Special Needs Plans
- Institutionalized (I-SNP) For those residing in nursing homes or similar care facilities, these plans are designed around their needs.
- Dual Eligible (D-SNP) For those that qualify for Maryland state assistance such as Medicaid or SSI. They are dual eligible for both Medicare and Medicaid and have plans designed specifically for them
- Chronic – (C-SNP) For those with a chronic health condition such as heart disease, ESRD, COPD, each of these plans specializes in one specific chronic condition. Doctor approval is required to finalize enrollment into a C-SNP plan.
If I have a preexisting condition, can I be denied coverage?
No, the only condition you cannot have is End Stage Renal Disease (ESRD). This is the only medical question on the entire application. As long as you don’t have ESRD, you will be approved as long as you have Medicare Part A and Medicare Part B.
Can my coverage be cancelled if I get sick?
No, this is against the law. Once you have the plan, your coverage cannot be terminated, even if you develop End Stage Renal Disease (ESRD). The only way the plan can terminate your coverage is if you fail to pay your Medicare Part B monthly premiums or the plan’s monthly premium if one is required, or if you move out of the plan’s service area (which is typically from one county or state to the next).
What if I move out of the plan’s service area, what happens then?
Medicare offers you a 63 day window in which you must obtain coverage from a different insurance plan. There will be no medical questions and you cannot be denied coverage. Most clients stay with the same company, but if the company you are currently with does not offer a plan in the county to which you are moving, then you must select one of the available plans in the area. It’s best to discuss your options with your Medicare Broker prior to moving.
If I join a Medicare Advantage Plan can I later go back to original Medicare and buy a Medicare Supplement Plan?
Yes. There are several ways this can happen and it is a very complex and sometimes confusing answer with lots of rules, regulations and timelines.
The first way this can happen is if you join a Medicare Advantage Plan for the very first time, you have a 12 month “free look” or “trial period” in which Medicare allows you to test-drive the plan. If during this 12 month trial period you decide you want Original Medicare, then you simply switch to Original Medicare and purchase a Medicare Supplement Plan and a Medicare Prescription Drug Plan. If you utilize this option, there are no medical questions to answer and you will be approved no matter what. After 12 months, you will need to be fully underwritten and you can be denied coverage based on your health history. As a special side-note, the company United Healthcare offers a 24 Month “free look” period for their Medicare Supplement Plan through AARP. They will let you into their plan within the first 24 months of testing out a Medicare Advantage Plan and they will not ask any health related questions and will accept your application no matter what.
The second way this can happen is during the Annual Open Enrollment period or AEP. This happens between October 15th and December 7th of each year and changes made during this period will take effect on January 1st. During this time, you will have coverage from your Medicare Advantage Plan until the 1st of the new year. To qualify, you must go through medical underwriting with your Medicare Supplement Plan company and be approved. Once approved, you can then apply for a Medicare Prescription Drug plan. Both will start on January 1st.
The third way to do this switch is during the Open Enrollment Period which his January 1st through March 31st. This is another period where you can apply for a Supplement Insurance plan and a prescription drug plan, and once approved, drop your Medicare Advantage Plan. The changes will take effect on February 1st, March 1st, or April 1st depending on your date selection. You will go through medical underwriting and you can be denied coverage based on your health history.
The last way this can happen is through a Special Election Period, or SEP. These SEP reasons allow you to switch back to Original Medicare and obtain a Medicare Gap Plan without having to answer medical questions (it’s Guaranteed Issue). This can only be done during the Annual Enrollment Period (10/15 – 12/07) and you must have a valid reason to drop your Medicare Advantage Part C plan.
There are more than a dozen reason you can find to trigger this Special Election Period (SEP) but some of the more popular reasons are:
- Your Medicare Advantage Plan raises their Dr or Specialist visit co-payment by more than 15%
- Example: In 2020 your Dr. copayment is $10. In 2021 they raise it to $12. This represents a 20% increase, which automatically triggers a SEP so you can move without any medical underwriting.
- Your Medicare Advantage Plan reduces any benefits.
- Example: In 2020 your Advantage Plan offers you 36 One-way transportation trips. In 2021 they reduce this to 35 One-way transportation trips. This is a reduction in benefits and automatically triggers a SEP so you can move without any medical underwriting.
- Your Medicare Advantage Plan increases their drug cost copayments by more than 15%.
- Example: In 2020 your Advantage Plan charges $45 copayment for Tier 3 brand medications and in 2021 raises that amount to $55. This represents a 22% increase in drug copayments which automatically triggers a SEP so you can move without any medical underwriting.
Please note that if you apply for a Prescription Drug Plan (PDP) prior to being approved for a Medicare Supplement Plan, the mere act of submitting your PDP application will automatically cancel your current Medicare Advantage Plan coverage.
Because of the unforgiving timelines, complexities and rules surrounding this type of plan change, it’s best to work with a knowledgeable Medicare Insurance Broker to ensure a smooth transition.
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