Out-of-network/non-contracted providers are under no obligation to treat Blue Cross NC members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

For each person who chooses to enroll in a Part C Medicare Advantage or other Part C plan, Medicare pays the health plan a set amount every month ("capitation"). The capitated fee associated with a Medicare Advantage plan is specific to each county in the United States and is primarily driven by a government-administered benchmark/bidding process that uses that county's average per-beneficiary FFS costs from a previous year as a starting point to determine the benchmark.
Tufts Health Unify, our Medicare-Medicaid One Care plan for people ages 21 – 64, gives you access to a network of providers, a dedicated care manager, a personalized care plan, and much more. You may be eligible for Tufts Health Unify if you live in Suffolk or Worcester counties of Massachusetts, are between the ages of 21 and 64, and are now enrolled in both Medicare and MassHealth.
You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2620 each calendar year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
If you’re looking for a Medicare Advantage Prescription Drug plan (that is, a Medicare Advantage plan with prescription drug coverage), you might want to make sure it covers the prescriptions you take. Each Medicare Advantage Prescription Drug plan has its own formulary (list of covered prescription drugs). The formulary may change at any time; you will receive notice from your plan when necessary.

Your information and use of this site is governed by our updated Terms of Use and Privacy Policy. By entering your name and information above and clicking the Have an Agent Call Me button, you are consenting to receive calls or emails regarding your Medicare Advantage, Medicare Supplement Insurance, and Prescription Drug Plan options (at any phone number or email address you provide) from an eHealth representative or one of our licensed insurance agent business partners, and you agree such calls may use an automatic telephone dialing system or an artificial or prerecorded voice to deliver messages even if you are on a government do-not-call registry. This agreement is not a condition of enrollment.
In 2002, payment rates were cut by 4.8%. In 2003, payment rates were scheduled to be reduced by 4.4%. However, Congress boosted the cumulative SGR target in the Consolidated Appropriation Resolution of 2003 (P.L. 108-7), allowing payments for physician services to rise 1.6%. In 2004 and 2005, payment rates were again scheduled to be reduced. The Medicare Modernization Act (P.L. 108-173) increased payments 1.5% for those two years.
If you decide to leave a Medicare Advantage plan and return back to Original Medicare, you must notify your Medicare Advantage plan carrier. Otherwise Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare. This is a common billing nightmare that we see among people who enrolled on their own without the help of an agent.
Medicare has four basic parts – A, B, C and D. If you’re unfamiliar with how they work, read Medicare 101: Do You Need All 4 Parts? Taken together, Parts A (hospital care), B (doctors, medical procedures, equipment) and D (prescription drugs) provide basic coverage for Americans 65 and older. What's relevant for this article is what these parts don't cover – deductibles, co-pays and other medical expenses that could wipe out your savings should you become seriously ill. That's where Part C comes in. Also known as Medicare Advantage, it's one of two ways to protect against the potential high cost of an accident or illness. Here's what could happen.
People often ask us our opinion on which plan is the best Medicare Advantage plan. This varies based on a number of personal factors. What’s right for your friend or neighbor may not be right for you. Don’t risk making a mistake on something as critical as your health insurance. Get help from an experienced agent who can explain your options in detail.
Remember, Medicare Advantage plans may offer additional benefits that are not offered in Original Medicare coverage. Beneficiaries who need prescription drug coverage may prefer the convenience of having all of their Medicare coverage included under a single plan, instead of enrolling in a stand-alone Medicare Prescription Drug Plan for Medicare Part D coverage. However, every person’s situation is different, so it’s a good idea to review your specific health needs, and compare Medicare Advantage plans in your area to find a plan option that best suits your needs.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
CMS and MedPAC now believe the "like beneficiary" calculations (those on A/B vs those on A/B/C) that have been used for a decade and that underlay many changes made by PPACA and subsequent regulations are not comparative and are misleading (see slide 8 of the January 12, 2017 MedPAC session on Medicare Advantage and other discussions on this subject since that time). That is because the calculations include the increasing number of people only on Part A (primarily because they did not "retire" at 65 given the higher Social Security full retirement age but did join Medicare Part A at 65 as recommended) whereas a "like" Medicare Part C beneficiary has to be on both Parts A and Part B. On an absolute basis, in 2015 Medicare spent 4% less on Medicare Advantage and other Part C beneficiaries per person than they did per person on Medicare beneficiaries under FFS Medicare.[9] In 2014 the difference in parity on an absolute basis was 2% less per person on Part C.[10] It appears from both points of view—per "like beneficiary" and absolutely—that the latest formula delivers the original cost-saving promise of Managed Medicare. But an absolute comparison is not totally accurate either.
Lifestyle: Medicare Advantage plans often only operate with a certain region. If you’re a snowbird living in more than one state throughout the year, traditional Medicare plus Medigap is probably a better choice than an Advantage plan. This may also be true if you travel frequently: Some Medigap plans provide coverage when traveling outside of the United States and cover you in all 50 states; Advantage plans generally do not. 

There are two ways for providers to be reimbursed in Medicare. "Participating" providers accept "assignment," which means that they accept Medicare's approved rate for their services as payment (typically 80% from Medicare and 20% from the beneficiary). Some non participating doctors do not take assignment, but they also treat Medicare enrollees and are authorized to balance bill no more than a small fixed amount above Medicare's approved rate. A minority of doctors are "private contractors," which means they opt out of Medicare and refuse to accept Medicare payments altogether. These doctors are required to inform patients that they will be liable for the full cost of their services out-of-pocket in advance of treatment.[60]


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.[12] Medicare added the option of payments to health maintenance organizations (HMO)[12] 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).

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