Should I Change to a Medicare Advantage Program? Pros and Cons…..


What is a Medicare private health plan (Medicare Advantage)?

While the majority of people with Medicare get their health coverage from Original Medicare, some people choose* to get their benefits from a Medicare private health plan, sometimes called a “Medicare Advantage” plan.

These private health plans contract with Medicare and are paid a fixed amount to provide Medicare benefits. They are generally “managed care plans.” The most common types are Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Private Fee-For-Service (PFFS) plans.

You may also see Medicare Advantage plans called Special Needs Plans (SNP), Provider Sponsored Organizations (PSO) and Medicare Medical Savings Accounts (MSAs).

You still have Medicare if you join a Medicare private health plan. In most cases, you must still pay your Part B monthly premium (and your Part A premium, if you have one). The plan must provide all Part A and Part B services but can do so with different rules, costs and restrictions that can affect how and when you can get care.

Starting in 2011, all private health plans must include a limit on your out-of-pocket expenses for Part A and B services. These limits tend to be high. Also beginning in 2011, plans can’t charge you more than Original Medicare for certain services, like chemotherapy and dialysis, but they can charge you more than Original Medicare for others, like home health and inpatient hospital services. Private plans can also provide additional benefits that Original Medicare does not cover, such as routine vision or dental care.

Different types of plans have different rules for how and where you can get coverage. However, even plans of the same type may have slightly different rules so you should always check with a plan directly to find out how coverage works.

Private health plans often charge a premium in addition to the Medicare Part B premium. They also generally charge a fixed amount called a “copayment” whenever you receive a service.

You can join any Medicare private health plan if:

  • You have Medicare Parts A and B; and
  • You live in the health plan’s service area; and
  • You do not have End-Stage Renal Disease (ESRD).
    • If you have ESRD that requires dialysis or a kidney transplant, you can enroll in an MA plan if you join a “Special Needs Plan” that specifically accepts people with ESRD or if other special circumstances apply.

If you want Medicare coverage through a prvate plan and also want drug coverage (Part D), you must generally choose a private health plan that has this drug coverage as part of its benefits package. (If you join an MSA, a PFFS without drug coverage, or a Cost Plan, you can join a stand-alone drug plan known as a PDP.)

 *Note: If you have health coverage from your union or current or former employer when you become eligible for Medicare, your coverage may automatically convert into a Medicare private health plan. You have the choice to stay with this plan, choose Original Medicare, or switch to another Medicare private health plan.

Be aware that if you switch to Original Medicare or another Medicare private health plan instead, the employer or union could terminate or reduce your health benefits, the health benefits of your dependents, and any other benefits you get from your company. Talk to your plan before switching to find out how your health benefits and other benefits will be affected.

  • In a Medicare Advantage plans (private health plans) you generally must pay the Medicare Part B premium. Some Medicare Advantage plans may also charge you an additional premium. In some cases, the plan may pay part of your Part B premium.
  • Medicare Advantage plans may make you pay a deductible for doctor visits, but some do not. However, they may charge a deductible for hospital visits and prescription drugs.
  • Medicare Advantage plans usually charge you a copayment—a fixed dollar amount—when you visit a doctor, instead of the 20 percent coinsurance you pay under Original Medicare.
  • All plans must include a limit on the amount of cost-sharing you will pay during the year. These limits include copays and deductibles. These limits may be high, but they will protect you from excessive out of pocket costs if you need a lot of care or expensive treatment.
  • Medicare Advantage plans cannot charge higher copayments than Original Medicare for certain care. This includes chemotherapy, dialysis and durable medical equipment. They can charge you more than Original Medicare for others services, including home health, skilled nursing facility and inpatient hospital services.
  • Many Medicare Advantage plans have a network of doctors, hospitals and pharmacies, and provide services only in a certain part of the country. You will have to pay more for your health services if you get care outside of the plan’s network or service area.
  • Different plans have different rules for how and where you can get coverage. You may have to pay the full cost of services yourself if you do not follow your Medicare Advantage plan’s rules.

Medicare Advantage plan (private health plan) coverage:

  • Before you join a Medicare Advantage plan, make sure you understand the plan’s costs, rules and restrictions. Medicare Advantage plans can be less costly than Original Medicare if you do not need a lot of care, but you have less freedom to decide when you get care, what care you get, and which doctors you use.
  • Medicare Advantage plans have a limit on your out-of-pocket costs (deductibles and co-pays). These limits may be high, but they will protect you from excessive out of pocket costs if you need a lot of care or expensive treatment.
  • Medicare Advantage plans cannot charge higher copayments than Original Medicare for certain care. This includes chemotherapy, dialysis and durable medical equipment. However, they can charge you more for other services, including home health, skilled nursing facility and inpatient hospital services.
  • Many plans cover services only if you receive them from doctors, hospitals and pharmacies that are in the plan’s network. Before you join a Medicare Advantage plan, make sure your doctors (or other providers you may want to use in the future) are in the network and that they are accepting new patients from the plan.
  • Even though Medicare Advantage plans must cover all health services that Original Medicare covers, they may ask you to pay more for certain services or require that you take certain steps before they will pay for your care. For example they can ask you to get official permission from the plan before receiving certain services; this is called “prior authorization”.
  • Medicare Advantage plans can put other restrictions on the care that you receive, such as requiring that you get a referral from your primary care doctor to see a specialist. They can also require that your doctor ask the plan’s permission before giving you certain services or drugs.
  • Medicare Advantage plans may also close, requiring you to find a new Medicare Advantage plan or return to Original Medicare.
  • Keep in mind that doctors and hospitals may leave the plan at any time, but you can only leave a Medicare Advantage plan at certain times of the year.
  • Finally, remember that you cannot buy a Medigap policy to supplement a Medicare Advantage plan. Medigap policies work only with Original Medicare.
  • The most common types of Medicare Advantage plans (private health plans) are Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Private Fee-For-Service (PFFS) plans.
  • You may also see Medicare Advantage plans called Special Needs Plans (SNP), Provider Sponsored Organizations (PSO) and Medicare Medical Savings Accounts (MSAs).
  •  You still have Medicare if you join a Medicare Advantage plan.

Different types of plans have different rules for how and where you can get coverage. However, even plans of the same type may have slightly different rules so you should always check with a plan directly to find out how coverage works.

Source: http://www.medicareinteractive.org/

Thousands of beneficiary calls to the Medicare Rights Center, lists nine common problems with Medicare Advantage plans. The problems include the following:

  • Care can cost more than it would under original Medicare.
  • Private plans are not stable and may suddenly cease coverage.
  • Members may experience difficulty getting emergency or urgent care.
  • Because plans only cover certain doctors, the continuity of care is often broken when the plan drops a provider.
  • Members have to follow plan rules to get covered care.
  • Members are restricted in their choices of doctors, hospitals, and other providers.
  • It can be difficult to get care away from home.
  • The extra benefits offered often turn out to be less than promised.
  • People with both Medicare and Medicaid can encounter higher costs.

Source: http://www.elderlawanswers.com/Default.aspx

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One thought on “Should I Change to a Medicare Advantage Program? Pros and Cons…..

  1. Pingback: Top 10 “Cloister Living” Posts | Cloister Living

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