Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare.
Most Medicare Advantage Plans include drug coverage (Part D). In many cases, you’ll need to use health care providers who participate in the plan’s network and service area for the lowest costs. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services, to help protect you from unexpected costs.
Some plans offer out-of-network coverage, but sometimes at a higher cost. Remember, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your red, white, and blue Medicare card in a safe place because you’ll need it if you ever switch back to Original Medicare.
Medicare Advantage Plans
Health Maintenance Organization – HMO
Preferred Provider Organization – PPO
Special Needs Plans (SNPs)
Veteran Plans
HMO - HEALTH MAINTENANCE ORGANIZATION
In HMO Medicare Plans, you generally must get your care and services from providers in the plan’s network, except:
In some Medicare plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO Medicare with a point-of-service (POS) option.
Prescription drugs are covered in HMO Medicare plans.
You need to choose a primary care doctor in HMO Medicare Plans.
In most cases you have to get a referral to see a specialist in HMO Medicare Plans. Certain services, like yearly screening mammograms, don’t require a referral.
If you get health care outside the plan’s network, you may have to pay the full cost.
It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
PPO- pREFERRED PROVIDER ORGANIZATION
A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.
In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.
In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn’t offer prescription drug coverage, you can’t join a Medicare drug plan (Part D).
You don’t need to choose a primary care doctor in PPO Plans. In most cases, no. But if you use plan specialists (in-network), your costs for covered services will usually be lower than if you use non-plan specialists (out-of-network).
Because certain providers are “preferred”, you can save money by using them.
A PPO Plan Isn’t the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.
It usually offers extra benefits than Original Medicare, but you may have to pay extra for these benefits.
Check with the plan for information.
sPECIAL NEEDS PLANS
There are several types of Special Needs Plans.
Chronic Condition SNPs (C-SNPs) are SNPs that restrict enrollment to individuals with certain chronic or disabling chronic conditions, such as diabetes, heart disease, lung conditions.
Each CSNP will specify the condition(s) necessary to be eligible to enroll.
Primary health related benefits for chronically ill enrollees may include items such as decreased cost sharing for certain services, or supplemental benefits such as at-home palliative care or transportation to medical appointments.
SSBCI may include items such as food and/or products, meals beyond a limited basis, pest control, and non medical transportation.
Dual eligible SNPs (D-SNPs) enroll beneficiaries who are entitled to both Medicare and medical assistance from a State plan under Medicare.
A subset of DSNPs, fully integrated Dual Eligible (FIDE) SNPs, provide dual-eligible enrollees access to Medicare and Medicaid benefits under a single managed care organization.
Medicare Advantage Plan Benefits
All Medicare Advantage (MA) plans must cover all Part A and Part B benefits.
Most Medicare Advantage plans also cover all or part of the Original Medicare cost-sharing for Part A and Part B benefits.
Medicare Advantage plans may also cover extra benefits not covered by Original Medicare, such as:
- Additional days of hospitalization
- Skilled nursing and rehabilitative services without a prior 3-day inpatient hospital stay
- vision services including glasses
- hearing aids
- routine dental services and/or dentures
- fitness (such as gym membership or Silver Sneakers)
- Meals related to a medical condition or after a hospitalization
- Worldwide Urgently Needsed and Emergency Services
- Over the Counter Drugs
REMEMBER: An annual physical is different from the annual wellness visit under Medicare, which does not include a physical exam.
what should veterans know about medicare?
1. Medicare and VA coverage do not coordinate benefits
Medicare and VA (Veterans Affairs) insurance do not coordinate coverage. The only instance in which the two programs might team up to offer dual coverage is when the VA approves qualified care to be received at a non-VA facility.
Medicare coverage for people with VA insurance typically works like this:
If you receive care at a VA facility, it will be covered by your VA insurance.
If you have Medicare and receive Medicare-approved care at a non-VA facility, Medicare will provide coverage. Medicare will not provide coverage at a VA facility, and VA benefits will not provide coverage at a non-VA facility.
In other words, you must visit a VA hospital or medical facility in order to use your VA coverage, and you must visit a civilian hospital or medical facility in order to use your Medicare coverage. VA benefits and Medicare coverage do not overlap.
2. There can be advantages to having both types of coverage
There can be some definite advantages in having VA benefits and Medicare insurance.
- Having both types of coverage can give you more health care options. If you only have VA insurance, you are limited to receiving covered care at only VA facilities. But adding Medicare coverage can open up the range of hospitals, doctor’s offices, pharmacies and other types of health care locations in which you may receive covered care.
- Having both types of coverage can benefit you in the event that an emergency occurs when you are not in close proximity to a VA hospital.
- Most people do not pay a premium for Part A Medicare.
3. You may not have the same VA coverage forever
Another reason you may consider enrolling in Medicare is the possibility that you may lose your VA benefits at some point, leaving you without health insurance coverage.
VA health benefits depend on an annual appropriation of funds by Congress, and it’s unpredictable if enough funding will be approved in future years to care for all veterans. Those veterans in the lower priority groups are at particular risk to see a reduction or even a complete loss of their veteran’s benefits.
4. Prescription drug coverage can vary
VA coverage includes prescription drug benefits, and for this reason, many VA members may choose not to enroll in Medicare Part D (Medicare prescription drug plans).
And because VA drug benefits are considered “creditable coverage” by Medicare, VA members are not required to pay a late enrollment penalty if they choose to sign up for Medicare Part D at a later date.
There are a few instances in which enrolling in a Part D plan or a Medicare Advantage plan with prescription drug coverage may make sense:
- VA coverage includes its own drug formulary (a list of drugs covered by the plan). If the VA does not cover a specific drug that you need to take, you might consider enrolling in a Medicare Part D plan that covers that drug.
- A drug prescribed by a doctor at a non-VA facility may not be covered by VA benefits without authorization.
- A non-VA pharmacy may be a more convenient way to obtain your drugs, especially if you reside in a nursing home or other long-term care facility.
- If you qualify for Medicare Extra Help, your overall drug costs may be lower with a Part D plan than under VA coverage.
- Check the VA formulary.
5. Medicare Advantage plans can be good options for veterans
A Medicare Advantage plan may be worth considering if you are a veteran.
A Medicare Advantage plan will provide all the same coverage as Original Medicare, and some Medicare Advantage plans may include a prescription drug plan.
Medicare Advantage or Medicare Supplement plan for Veterans just might alleviate some of these costs. Please call (702) 541-0882 to speak with a licensed representative.