Medicare
Advantage
Part C

Basic Medicare Advantage Things to Know…

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If you are deciding between Medicare Advantage and Medicare Supplement (Medigap) plans, you should consider some of the rules before you enroll.

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• Medicare Advantage plans use network doctors and hospitals for the lowest out-of-pocket costs. Plans may have HMO or PPO networks. Most Medicare HMO plans do not cover anything out of network except emergencies. In PPO networks, seeing a provider outside the network will result in higher spending for you.

• Advantage plans may require prior authorization for certain procedures

• You may need to obtain a referral from your primary care physician before seeing a specialist on many HMO plans

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How Medicare Advantage Works

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A Medicare Advantage plan is a private Medicare insurance plan that you may join

as an alternative way to get your Medicare benefits. When you do, Medicare pays

the plan a fee every month to administer your Part A and B benefits.

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You must continue to enroll in Medicare Part A and B while enrolled in your

Medicare Advantage plan. Medicare pays the Medicare Advantage company to

take on your medical risk, which is how Medicare Advantage plans are funded.

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You will present your Medicare  Advantage plan ID card during your doctor visits or specific treatments. Your providers will bill the plan instead of Original Medicare. You may always return to Original Medicare during the Annual Enrollment Period or the Open Enrollment Period.

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You must direct your providers to bill your Medicare Advantage plan. People who enroll in Medicare Advantage plans agree to be covered by the plan instead of Original Medicare for the rest of the calendar year.

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Medicare Advantage Networks

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Most Medicare Advantage plans have HMO or PPO networks.

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Medicare HMO networks are generally required to serve only with network providers, except in emergencies. You will usually need to select a primary care physician. That physician can coordinate a referral if you need to see a specialist. Some HMO plans offer a Point-of-Service (POS) feature where you can see out-of-network providers in certain circumstances.

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Medicare PPO networks allow you to see doctors outside the network, but you may have substantially higher out-of-pocket spending to do so.

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In limited counties, there are Medicare Private-Fee-for-Service plans. These plans may or may not include Part D. How you access care is also different. While this plan type was very common in the past, it has been slowly phased out in most areas.

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Medicare Advantage Enrollment Periods

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Enrollment periods are specific times during the year when people may change their Medicare Advantage plans. Specific rules allow individuals to make changes during these periods, and it may be important to speak with a licensed agent who can advise them so that important deadlines are not missed.  

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Special Enrollment Period (SEP)

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When someone turns 65, or when someone younger than 65 receives Social Security disability and has received their benefits for at least 24 months, they will have an opportunity to enroll in a Medicare Advantage plan of their choice.

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Annual Enrollment Period (AEP)

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The Annual Enrollment Period (AEP) occurs from October 15th to December 7th each year. During this time, Medicare recipients may change their plan options. They may either change to a different Medicare Advantage plan, leave Original Medicare and enroll in a Medicare Advantage Plan, or leave a Medicare Advantage plan and return to Original Medicare. Any changes made to their enrollment will take effect on January 11th of the new plan year.

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If they decide to leave a Medicare Advantage plan and return to Original Medicare, the member must notify their Medicare Advantage plan carrier. Otherwise, Medicare will continue to show them as enrolled in the Advantage plan instead of Medicare. Note: If they are returning to Original Medicare, they must purchase a standalone Part D drug plan to receive their prescriptions, and this will also become effective on January 1st of the new plan year.

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Open Enrollment Period (OEP)

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The Medicare Advantage Open Enrollment Period runs from January 1st to March 31st each year. During this time, people may disenroll from any Medicare Advantage plan and return to Original Medicare. They will also be allowed to add a standalone Part D drug plan.

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Medicare vs Medicare Advantage

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Here are some of the reasons a person might choose a Medicare Advantage plan:

• Many plans have low monthly premiums (although you must continue to pay your Medicare Part B premium)

• You pay for medical services as you use them in the form of copays and coinsurance

• Unlike Original Medicare, Medicare Advantage plans have an out-of-pocket maximum cap to protect you against catastrophic spending.

• The convenience of having your medical and Part D drug benefits rolled into one plan.

• Some plans may include dental, vision, and over-the-counter benefits. However, limitations, copayments, and restrictions may apply.

• This plan lowers the out-of-pocket costs of Original Medicare​

• Medicare Advantage plans include emergency coverage when traveling outside the US.

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Remember, it's a personal choice - there is no right and wrong. Consider Original Medicare vs Medicare Advantage based on your knowledge of your medical usage.

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Medicare Advantage vs Medicare Supplement (Medigap) Plans

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Without question, Original Medicare with a Medicare Supplement (Medigap) plan gives you very comprehensive coverage. The primary difference is that with Medigap plans, you can see any doctor who accepts Medicare. You don't have to ask your doctors if they take your specific Medigap insurance company. The network is Medicare, which has over 1 million contracted providers nationwide.

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Some Medicare Supplement (Medigap) plans also have fuller coverage on the back end. Medicare pays 80%, and your Medigap plan can pay some or all of the other 20%, depending on which Medigap plan you choose. This leaves you with little out-of-pocket. For example, a beneficiary with a Medicare Supplement (Medigap) Plan G won't have the repetitive copays at the doctor that they might incur on a Medicare Advantage plan.

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However, Medicare Supplement (Medigap) plans do not include Part D coverage, so you must buy a separate Part D policy. They also do not offer routine dental, vision, or hearing coverage, while some Medicare Advantage plans may at least offer some of this.

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​Medicare Special Needs Plans

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Medicare Special Needs Plans (SNPs) are a type of Medicare Advantage plan that provides coordinated care to beneficiaries with specific needs or situations.

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These SNPs limit membership to beneficiaries with specific illnesses, chronic conditions, or circumstances, such as being eligible for both Medicare and Medicaid. The plans must include all the same services as Original Medicare Parts A and B.

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Special Needs Plans tailor their plan benefits, network, and drug formulary to meet the needs of individuals with these specific health conditions or circumstances. All Special Needs Plans include a built-in Part D drug plan.

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Chronic Illness Special Needs Plan

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A Medicare Advantage Special Needs Plan based on health conditions is a plan that is specifically designed to provide excellent support for individuals with chronic illness. For example, the SNP might provide access to providers specializing in treating specific illnesses.

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These providers work together to coordinate your care. The plan will often assign a care coordinator or case manager to assist you with staying healthy, managing your health condition, and following your provider’s orders. He or she might also help you access community resources or get the right prescriptions promptly.

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The drug formulary built into the plan will also likely offer a robust list of drugs that treat this particular health condition.

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To qualify for a chronic illness SNP, you must have one or more of the health conditions listed below:

• Cardiovascular disease, stroke, or chronic heart failure

• Alzheimer’s or Dementia

• Diabetes

• ESRD requiring dialysis

• HIV or AIDS

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To join a Chronic Illness SNP, your doctor must complete a chronic condition verification form at the time of enrollment and return it to verify your eligibility.

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Chronic Illness SNPs vary by county. Insurance companies get to choose where they will offer specific plan designs, so you may or may not be able to find an SNP in your area that specializes in the condition that you have. Check with your Medicare insurance broker to see what is offered.

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Institutional Special Needs Plan (ISNP)

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Medicare beneficiaries who live in an institution, such as an assisted living center, nursing home, or memory care center, may qualify for an Institutional SNP.

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These plans are similar to those of the chronic illness SNP, but instead, they focus on providing coordinated care to someone who is no longer living independently. The beneficiary must be expected to live in the institution for at least 90 days.

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Dual Eligible Special Needs Plan (DSNP)

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Some Medicare beneficiaries also qualify for Medicaid, a federal and state health insurance program for low-income people.

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When you qualify for both, you can keep your Original Medicare and have Medicaid as your secondary coverage or enroll in a Dual Eligible Special Needs Plan.

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People with full Medicaid can expect to spend little to nothing on deductibles, copays, and coinsurance for Part A and B services provided by the plan.  Many plans have a $0 premium because Medicaid pays any plan premium for you. People with partial Medicaid may have to pay some cost-sharing.

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Dual Special Needs Plans often also offer rich ancillary benefits. These might include:

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• Quarterly benefits for over-the-counter products

• Telemedicine services

• Transportation to and from doctor appointments or trips to the pharmacy

• Routine dental, vision, and hearing benefits

• Gym memberships

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The plan or your agent will need to verify your eligibility for Medicaid before they can enroll you into the DSNP plan.

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Enrolling in an SNP

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To qualify for enrollment into a Special Needs Plan, you must live in the plan’s service area and be enrolled in both Medicare Parts A and B. You will continue to pay your Part B premium to Social Security the entire time you are enrolled in the plan (unless this is covered for you by Medicaid.)

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You will also pay any monthly premium the plan charges for the SNP. Finally, you will pay the regular cost-sharing expenses, such as deductibles, copays, and coinsurance. These amounts can be found in the plan’s Summary of Benefits, which you should review before joining.

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You can enroll in a Medicare Advantage SNP during your Initial Enrollment Period for Medicare or during any Medicare Fall Annual Election Period. Some people may also qualify for Special Enrollment Periods during the year in certain situations. These include:

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• Moving outside of your current plan’s service area

• Qualifying for Medicaid

• Moving into, living in, or moving out of an institution

• Being diagnosed with a severe or chronic condition that qualifies you for a Chronic condition SNP

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If you lose your eligibility for an SNP, you will have a grace period within which you can leave the plan and join another plan or return to Original Medicare.

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How do you know which plan is right for you?!

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This varies based on several personal factors, and no right or wrong answer exists. What's right for a friend or neighbor may not be right for you.