Advantage plan benefits may change every year. In September, you will receive a packet from your Part C insurance company telling you what is changing. The plan’s benefits, formulary, pharmacy network, provider network, premium and/or co-payments and co-insurance may change on January 1 of each year. Will you be diligent enough to review your annual packet and communicate with your agent if you have concerns about the changes?
Medicare Advantage plans are required to offer a benefit "package" that is at least equal to Original Medicare's and cover everything Medicare covers, but they may cover benefits in a different way. For example, plans that require higher out-of-pocket costs than Original Medicare for some benefits, such as skilled nursing facility care, might offer lower copayments for doctor visits to balance their benefits package. CMS limits the extent to which plans' cost-sharing can vary from that of Original Medicare. Medicare Advantage plans that receive "rebates" or quality-based bonus payments are required to use the money to provide benefits not covered by Original Medicare.
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In the 1970s, less than a decade after the beginning of fee for service Medicare, Medicare beneficiaries gained the option to receive their Medicare benefits through managed, capitated health plans, mainly HMOs, as an alternative to FFS Original Medicare, but only under random Medicare demonstration programs. The Balanced Budget Act of 1997 formalized the demonstration programs into Medicare Part C, introduced the term Medicare+Choice as a pseudo-brand for this option. Initially, fewer insurers participated than expected, leading to little competition. In a 2003 law, the capitated-fee benchmark/bidding process was changed effective in 2005 to increase insurer participation, but also increasing the costs per person of the program.
Medicare beneficiaries in Minnesota have the option to enroll in a Medicare Advantage plan as an alternative way to get their Original Medicare, Part A and Part B, coverage. Also known as Medicare Part C, Medicare Advantage plans are available through private insurance companies that contract with Medicare. All Medicare Advantage plans are required to provide at least the same level of coverage as Original Medicare, meaning you’ll get the same hospital and medical benefits of Part A and Part B through your Medicare Advantage plan. In addition, some Medicare Advantage plans may also offer additional benefits, such as routine dental, vision, hearing, or prescription drugs.
ACA provided bonus payments to plans with ratings of 4 (out of 5) stars or more. The Obama administration launched an $8.35 billion demonstration project in 2012 that increased the size of the bonus payments and increased the number of plans receiving bonus payments, providing bonus payments to the majority of Medicare Advantage plans. According to the Government Accountability Office (GAO) this demonstration project cost more than the previous 85 demonstration projects beginning in 1995 combined.
Medi-Cal is California’s state-managed version of Medicaid, a federal health insurance program designed for low-income individuals and families. It provides low-cost and no-cost health insurance coverage to individuals and families that meet certain eligibility requirements.* Those who qualify for Medi-Cal coverage can continue to receive those benefits as long as they meet eligibility requirements.
So, is a Medicare Advantage plan right for you? And, should you get one with or without prescription drug coverage? The decision probably depends on your particular situation. I can work with you to get answers. Learn more about me by viewing my profile using the “View profile” link below. Or, use one of the links below to request a time to meet with me by phone or an email with personalized information for you. Compare the Medicare Advantage plans that you might be eligible for by clicking on the Compare Plans buttons on this page.
Original "fee-for-service" Medicare Parts A and B have a standard benefit package that covers medically necessary care as described in the sections above that members can receive from nearly any hospital or doctor in the country (if that doctor or hospital accepts Medicare). Original Medicare beneficiaries who choose to enroll in a Part C Medicare Advantage health plan instead give up none of their rights as an Original Medicare beneficiary, receive the same standard benefits—as a minimum—as provided in Original Medicare, and get an annual out of pocket (OOP) upper spending limit not included in Original Medicare. However they must typically use only a select network of providers except in emergencies, typically restricted to the area surrounding their legal residence (which can vary from tens to over 100 miles depending on county). Most Part C plans are traditional health maintenance organizations (HMOs) that require the patient to have a primary care physician, though others are preferred provider organizations (which typically means the provider restrictions are not as confining as with an HMO), and a few are actually fee for service hybrids.
Most people fill Medicare’s coverage gaps by buying a Medicare supplement (medigap) plan and a Part D prescription-drug plan, or they get both medical and drug coverage from a private insurer with a Medicare Advantage plan. You have from October 15 to December 7 each year to pick a Medicare Part D prescription-drug plan or a Medicare Advantage plan for the year ahead. You can switch from one Part D plan to another, or from one Medicare Advantage plan to another. You can also switch into a Medicare Advantage plan. However, if you have Medicare Advantage and want to switch to a medigap plan plus a Part D plan, you may have limited medigap options depending on your health—although you can choose any Part D plan during open enrollment. (For more information about how to choose between Medicare Advantage or medigap and Part D, see How to Fill Medicare Coverage Gaps).
MA plans feature a network of doctors and hospitals that enrollees must use to get the maximum payment, whereas supplements tend to provide access to a broader set of health care providers, said Shawnee Christenson, an insurance agent with Crosstown Insurance in New Hope. While that might sound good to beneficiaries, supplements can come with significantly higher premiums, Christenson said.
Medicare Part B premiums are commonly deducted automatically from beneficiaries' monthly Social Security checks. They can also be paid quarterly via bill sent directly to beneficiaries. This alternative is becoming more common because whereas the eligibility age for Medicare has remained at 65 per the 1965 legislation, the so-called Full Retirement Age for Social Security has been increased to 66 and will go even higher over time. Therefore, many people delay collecting Social Security and have to pay their Part B premium directly.
Medicare has been operated for a half century and, during that time, has undergone several changes. Since 1965, the program's provisions have expanded to include benefits for speech, physical, and chiropractic therapy in 1972. Medicare added the option of payments to health maintenance organizations (HMO) in the 1980s. As the years progressed, Congress expanded Medicare eligibility to younger people with permanent disabilities and receive Social Security Disability Insurance (SSDI) payments and to those with end-stage renal disease (ESRD). The association with HMOs begun in the 1980s was formalized under President Bill Clinton in 1997 as Medicare Part C (although not all Part C health plans sponsors have to be HMOs, about 75% are). In 2003, under President George W. Bush, a Medicare program for covering almost all self administered prescription drugs was passed (and went into effect in 2006) as Medicare Part D (previously and still, professionally administered drugs such as chemotherapy but even the annual flu shot are covered under Part B).