Medicare Part C

Last updated: October 7, 2015

Medicare Advantage Plans

What Are Medicare Advantage Plans?

Medicare Advantage Plans are an alternative way of receiving Part A and Part B coverage. For more information click here. Choosing a Medicare Advantage Plan takes the place of Original Medicare. You cannot have both.

The Kansas Insurance Department has no direct regulatory authority over Medicare Advantage Plans.

Private insurance companies manage Medicare coverage for their members. They may also provide extra benefits not included in Original Medicare, such as dental, vision, or hearing coverage. These plans include all benefits from Part A and Part B. Some plans also include Part D prescription drug coverage.

Medicare Advantage plans differ from Original Medicare because they use provider networks. Using the services of doctors and hospitals outside of the network may cost you an additional fee.

Types of Provider Networks:

The types of provider networks included in the Medicare Advantage plans are Health Maintenance Organizations (HMOs); Preferred Provider Networks (PPOs); Private Fee-For-Service (PFFS); Special Needs Plans (SNPs); and Medical Savings Accounts (MSA).

Health Maintenance Organizations (HMOs)

  • Generally, in Kansas, you can only go to doctors, specialists, or hospitals on the plan’s list, except in emergency situations. This is called the plan’s "network."

  • You may also have to choose a primary care doctor and get referrals to see a specialist.

  • You may pay lower copayments and get extra benefits, such as coverage for extra days in the hospital.

Preferred Provider Organization Plans (PPOs)

  • In most of these plans, you use doctors, specialists, and hospitals in the plan’s network.

  • You can go to doctors, specialists, or hospitals not in the plan’s network, but it may cost extra.

  • You don’t need referrals to see doctors, specialists, or hospitals who aren’t part of the plan’s network.

  • You may pay lower copayments and get extra benefits, such as coverage for extra days in the hospital.

Private Fee-for-Service Plans (PFFS)

  • These plans allow you to go to any primary care doctor, specialist, or hospital that accepts the terms of the plan’s payment.

  • The private company, rather than Medicare, decides how much it will pay and how much you pay for the services you get.

Special Needs Plan (SNPs)

  • Medicare Special Needs Plans are specially designed for people with certain chronic diseases and other specialized health needs.

  • These plans must provide all the same benefits provided by Part A and Part B. They also must provide Medicare prescription drug coverage (Part D).

  • Generally, they offer extra benefits and have lower copayments than the Original Medicare plan.

  • Special Needs Plans are designed to meet the needs of people who live in certain institutions (like a nursing home), are eligible for both Medicare and Medicaid, or have one or more specific chronic or disabling conditions.

  • A Special Needs Plan may help manage and coordinate the many services and providers their members use to help them stay healthy. They also help members follow their doctor’s orders related to diet and prescription drugs, and help coordinate between Medicare and Medicaid.

  • They may also identify care provider efforts to meet the patient’s needs. For example, a Special Needs Plan for people with diabetes might use a care coordinator to help members monitor blood sugar, follow their diet, get proper exercise, get needed preventive services such as eye and foot exams, and get the right medicines to prevent complications.

Medical Savings Account Plans (MSAs)

Medical Savings Account Plans (MSAs) are similar to Health Savings Account plans available outside of Medicare. They have two parts:

  • The first part is a Medicare Advantage health plan with a high deductible. This health plan won’t begin to pay covered costs until you have met the annual deductible, which varies by plan.

  • The second part is a Medical Savings Account into which Medicare deposits money that you may use to pay health care costs.

What Will I Pay for a Medicare Advantage Plan?

Because Medicare Advantage Plans are run by private insurance companies, costs will vary. Some factors that contribute to the costs of Medicare Advantage plans include the following:

  • Whether the plan charges a monthly premium, and how much that premium is.

  • Whether the plan pays any of your monthly Part B premium.

  • Whether the plan charges a yearly deductible.

  • Whether the plan has any copayments or coinsurance costs, and how much they are.

  • The type of health care services you need and how often they are needed.

  • Whether you follow the rules of the plan (including extra charges for using out-of-network providers).

  • Whether you need extra benefits, and how much the plan charges for those benefits.

  • The plan’s yearly limit for out-of-pocket costs.

Medicare supplement insurance cannot be used if you have a Medicare Advantage Plan. If you switch to an Advantage Plan, but already have a Medicare supplement plan, you cannot use that coverage to pay for out-of-pocket expenses. Likewise, if you are enrolled in a Medicare Advantage Plan, you cannot be sold a Medicare supplement plan.

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