Medicare Advantage plans are privately owned Medicare plans offered by health insurance companies. While they are regulated by CMS (Centers for Medicare and Medicaid Services), they are not government health plans. This means that they are required to cover everything that the Medicare program covers, but they have the freedom to include additional benefits. These plans are often called “Part C” or abbreviated as “MA.” Use this guide to find out if Part C plans are right for you.
Medicare Advantage plans are NOT the same as traditional Medicare. Traditional, otherwise known as “Original” Medicare is a government-funded program, but MA plans are owned by private insurance companies. All American citizens are eligible for Original Medicare upon turning 65. Original Medicare includes “Part A,” coverage for hospital services, and “Part B,” coverage for physician services. Then, all seniors and Medicare eligibles are eligible to enroll in a separate prescription drug plan known as “Part D.” At this point, you’re probably wondering, “that’s A, B, and D...what about Part C?”
One of the most common questions we get is, “Do I need Medicare Part C?” You are not required to enroll in Medicare Part C, but we recommend it for most clients. Thanks in part to new laws passed in 2018, Part C plans have some flexibility when it comes to benefits. They can cover “daily maintenance” items like wheelchair ramps and home modifications as well as durable medical equipment, home health services, and telehealth. They can also cover transportation services to help you get to your doctor’s office or pharmacy.
New in 2018 is the ability for MA plans to offer coverage for doctor house calls, home nurses or aides to help with dressing and daily activities, non-emergency transportation, and over-the-counter pharmacy products. Non-emergency transportation refers to the ability to schedule a ride to your doctor appointments or in some cases, the pharmacy. Transportation services are usually offered through third-party companies (sometimes even through ridesharing services like Uber and Lyft) that your health plan is contracted with, so be sure to contact a company that your plan covers. The biggest change between 2017 and 2018 is that MA plans can now offer “non-skilled” home care. That refers to services that do not require a licensed doctor or nurse practitioner, such as home cleanup and meal delivery.
Even more exciting than the non-skilled home health benefit is telehealth! Telehealth services allow people who cannot leave their home either for medical reasons or for lack of transportation to easily access healthcare online. In this digital age, it seems like a waste to not take advantage of technology when it comes to healthcare. If your plan allows telehealth, there will be a list of telehealth providers you can use that will allow you to speak to doctors over the phone or via video chat. Doctors are often able to prescribe medications without you having to travel to their offices. In many cases, you can then have those prescriptions delivered through CVS Pharmacy or any other mail-order pharmacy.
Original Medicare only covers medical equipment that is considered “durable.” This usually means the item must be usable (at home) for at least three years. That includes items like oxygen equipment, nebulizers, infusion pumps, wheelchairs, etc. Unfortunately, this does not include home modifications. MA plans, however, can cover modifications. These can include wheelchair ramps, bathroom support bars, stair lifts, automatic doors, etc.
Another type of coverage that Part C plans often provide is for physical fitness. Usually, this comes in the form of a membership to a third-party program. The two most popular are SilverSneakers and Silver & Fit. If one of these programs is built into your MA coverage, you will have access to a gym membership and special group fitness classes designed for seniors and Medicare eligibles. Silver & Fit even offers “home fitness kits” for those who need to or prefer to stay at home.
Original Medicare does not cover dental, vision, and hearing services*, but Medicare Part C plans can. Though every plan is different, MA plans can cover dental exams and cleanings, x-rays, fillings, extractions, root canals, crowns, and even dentures in some cases. There are usually copayments associated with these services, but again, every plan is different. MA plans can also cover vision benefits like exams, glasses, and sometimes contact lenses. Possible hearing benefits include exams and hearing aids. If your plan covers dental, vision, and hearing, make sure that you find an audiologist in your plan network.
*Part A may be able to cover dental, vision, and hearing procedures if they are related to another hospital stay.
When shopping for a MA plan, you can purchase a MA only plan or a MAPD plan. MAPD stands for “Medicare Advantage Prescription Drug” plan and is simply a version of MA that includes prescription drug coverage. Enrolling in a MAPD plan means that you do not have to enroll in Part D or another form of prescription drug coverage. Instead, all of your coverage will be bundled into one convenient plan. Like any other prescription drug plan, your MAPD coverage will come with a drug formulary, a list of prescriptions that your plan covers. Most formularies are split into separate tiers that indicate what your co-payment will be for each prescription. Even though you may have co-payments for your prescriptions with a MAPD option, there are $0 premium plans available in some areas.
In short, traditional Medicare is a government program, but Medicare Part C plans are owned and operated by private insurance companies. However, that does not mean that they are less regulated than traditional Medicare. CMS, the Centers for Medicare and Medicaid Services, heavily regulates these plans and set limits on what benefits carriers can offer. Regardless, MA plans offer many more benefits than traditional Medicare.
The plans you are able to enroll in will vary based on where you are located. Most Medicare Part C plans are only available in certain states and counties. Each plan will be customized to its location and will have its own provider network. Your doctors and pharmacists will most likely not accept every plan, so a good place to start would be figuring out which plans your favorite doctors and pharmacies accept.
There are six major types of MA/Part C plans. The first four are commonly referred to as Coordinated Care plans. Not all options are available for everyone. Contact Medicare Plan Finder to get in touch with a benefits advisor who can help you select the best type of Part C plan for you and your needs, or call now at 833-328-3676.
In some cases, MA plans may appear to be more expensive than Original Medicare. However, if costs are higher, it's usually because you're getting more coverage. Some MA plans are cheaper than others, but generally the more expensive plans provide more benefits. Some people may be eligible for a $0 premium MA plan. Ask your agent about this.
As you may know, every age-in Medicare beneficiary begins with an “Initial Enrollment Period.” The IEP lasts from three months before your 65th birthday through three months after. During that time, you can enroll in traditional Medicare or you can choose to enroll in MA. If you do not enroll in Part C during your IEP, you can select an MA plan during AEP.
AEP is the Annual Enrollment Period; it occurs every October 15 through December 7 and is a time when any Medicare beneficiary can make plan changes. Some special circumstances may allow you to enroll during other times of the year, but most people will have to make their selections during AEP.
If you neglect to enroll in Medicare plan during your IEP, you may be stuck with a late enrollment penalty fee. The penalty is designed to encourage you to enroll as early as you are eligible. Even though you can enroll in MA or change into a new MA plan during the AEP every year, you still need to enroll in Medicare when you first become eligible.
Some people may be eligible for a special enrollment period! That means that during each of the first three quarters of the year, you have one opportunity to switch plans if you discover a plan that is better for your needs.
Oftentimes people who are eligible for a Medicare Savings Program, a State Pharmaceutical Assistance Program (SPAP), a SNP (Special Needs Plan), or Social Security benefits are eligible for a special enrollment period. People who qualify for both Medicare and Medicaid are also often eligible. There may be some limitations (for example, those at risk for opioid addiction may not be able to switch plans).
Additionally, some circumstances will allow Medicare beneficiaries a temporary special enrollment period. If you move to a new service area (like a new county), lose or gain a job, move into or out of a facility, leave imprisonment, or lose Medicaid eligibility, you will be granted a 60-day period to find a new plan that better fits your needs.
If you decide that you are not happy with your MA plan, you have a few options. You can switch to a different type of plan during the Annual Enrollment Period, or you may be eligible for the Open Enrollment Period (OEP).
If you realize that the plan you chose does not actually cover everything you need it to, or your doctor is not in your network, you can make one change from January 1 through March 31. This period is not the same as the Annual Enrollment Period - there are only a few types of changes you can make. You can switch from one MA plan to another MA plan, or you can switch from MA (or MAPD) back to plain Original Medicare (with the option to add Part D).
You are eligible for MA as long as you live in a service area that offers it and you already have Original Medicare (Part A and Part B). The only exception is for those who have ESRD (End-Stage Renal Disease). There are only a few MA plans that will cover people who have ESRD, and they only exist in a few specific service areas. A Medicare Plan Finder agent in your area can help you find out if there is an ESRD-friendly Medicare Advantage plan available to you.
You’re in the right place! Medicare Plan Finder is a great place to start for getting one of these plans. We have MA agents in 38 states who can sell plans from most major carriers. Contact Medicare Plan Finder to discuss your Medicare options. There is never any obligation to buy, and all of the information is free. Give us a call at 833-438-3676.
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