What hap­pens with a Medi­care Ad­van­tage Plan?

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Medi­care Ad­van­tage Plans, some­times called “Part C” or “MA Plans,” are of­fered by pri­vate com­pa­nies ap­proved by Medi­care. If you join a Medi­care Ad­van­tage Plan, you still have Medi­care. You’ll get your Medi­care Part A (Hospi­tal In­sur­ance) and Medi­care Part B (Med­i­cal In­sur­ance) cov­er­age from the Medi­care Ad­van­tage Plan and not from Orig­i­nal Medi­care.

Cov­ered Ser­vices in Medi­care Ad­van­tage Plans Medi­care Ad­van­tage Plans cover all Medi­care ser­vices. Medi­care Ad­van­tage Plans may also of­fer ex­tra cov­er­age. Medi­care Ad­van­tage Plans must cover all of the ser­vices that Orig­i­nal Medi­care cov­ers ex­cept hos­pice care. Orig­i­nal Medi­care cov­ers hos­pice care even if you’re in a Medi­care Ad­van­tage Plan. In all types of Medi­care Ad­van­tage Plans, you’re al­ways cov­ered for emer­gency and ur­gently needed care.

Medi­care Ad­van­tage Plans may of­fer ex­tra cov­er­age, like vi­sion, hear­ing, den­tal, and/or health and well­ness pro­grams. Most in­clude Medi­care pre­scrip­tion drug cov­er­age (Part D). In ad­di­tion to your Part B pre­mium, you usu­ally pay a monthly pre­mium for the Medi­care Ad­van­tage Plan.

The plan can choose not to cover the costs of ser­vices that aren’t medi- cally nec­es­sary un­der Medi­care. If you’re not sure whether a ser­vice is cov­ered, check with your provider be­fore you get the ser­vice.

You can also ask the plan for a writ­ten ad­vance cov­er­age de­ci­sion to make sure a ser­vice is med­i­cally nec­es­sary and will be cov­ered. If the plan won’t pay for a ser­vice you think you need, you’ll have to pay all of the costs if you didn’t ask for an ad­vance cov­er­age de­ci­sion.

If you need a ser­vice that the plan says isn’t med­i­cally nec­es­sary, you may have to pay all the costs of the ser­vice, but you have the right to ap­peal the de­ci­sion. Rules for Medi­care

Ad­van­tage Plans Medi­care pays a fixed amount for your care each month to the com­pa­nies of­fer­ing Medi­care Ad­van­tage Plans. These com­pa­nies must fol­low rules set by Medi­care.

How­ever, each Medi­care Ad­van­tage Plan can charge dif­fer­ent outof-pocket costs and have dif­fer­ent rules for how you get ser­vices (like whether you need a re­fer­ral to see a spe­cial­ist or if you have to go to only doc­tors, fa­cil­i­ties, or sup­pli­ers that be­long to the plan for non-emer­gency or non-ur­gent care). These rules can change each year. What you pay in a Medi­care

Ad­van­tage Plan What you pay in a Medi­care Ad­van­tage Plan de­pends on sev­eral fac­tors. Your out-of-pocket costs in a Medi­care Ad­van­tage Plan (Part C) de­pend on:

• Whether the plan charges a monthly pre­mium.

• Whether the plan pays any of your monthly Medi­care Part B (Med­i­cal In­sur­ance) pre­mium.

• Whether the plan has a yearly de­ductible or any ad­di­tional de­ductibles.

• How much you pay for each visit or ser­vice (co­pay­ment or coin­sur­ance). For ex­am­ple, the plan may charge a co­pay­ment, like $10 or $20 ev­ery time you see a doc­tor. These amounts can be dif­fer­ent than those un­der Orig­i­nal Medi­care.

• The type of health care ser­vices you need and how of­ten you get them.

• Whether you go to a doc­tor or sup­plier who ac­cepts as­sign­ment (if you’re in a PPO, PFFS, or MSA plan and you go out-of-net­work).

• Whether you fol­low the plan’s rules, like us­ing net­work providers.

• Whether you need ex­tra ben­e­fits and if the plan charges for it.

• The plan’s yearly limit on your out-of-pocket costs for all med­i­cal ser­vices.

• Whether you have Med­i­caid or get help from your state. Drug cov­er­age in Medi­care

Ad­van­tage Plans You usu­ally get pre­scrip­tion drug cov­er­age (Part D) through the plan. In some types of plans that don’t of­fer drug cov­er­age, you can join a Medi­care Pre­scrip­tion Drug Plan.

You can’t have pre­scrip­tion drug cov­er­age through both a Medi­care Ad­van­tage Plan and a Medi­care Pre­scrip­tion Drug Plan. If you’re in a Medi­care Ad­van­tage Plan that in­cludes drug cov­er­age and you join a Medi­care Pre­scrip­tion Drug Plan, you’ll be dis­en­rolled from your Medi­care Ad­van­tage Plan and re­turned to Orig­i­nal Medi­care. How Medi­care Sup­ple­ment In­sur­ance (Medi­gap) poli­cies work with Medi­care

Ad­van­tage Plans Medi­gap poli­cies can’t work with Medi­care Ad­van­tage Plans. If you have a Medi­gap pol­icy and join a Medi­care Ad­van­tage Plan (Part C), you have to can­cel your Medi­gap pol­icy.

To can­cel your Medi­gap pol­icy, con­tact your in­sur­ance com­pany. If you leave the Medi­care Ad­van­tage Plan, you might not be able to get the same Medi­gap pol­icy back, or in some cases, any Medi­gap pol­icy un­less you have a “trial right.”

If you have a Medi­care Ad­van­tage Plan, it’s il­le­gal for any­one to sell you a Medi­gap pol­icy un­less you’re switch­ing back to Orig­i­nal Medi­care. If you want to switch to Orig­i­nal Medi­care and buy a Medi­gap pol­icy, con­tact your Medi­care Ad­van­tage Plan to see if you’re able to dis­en­roll.

If you join a Medi­care Ad­van­tage Plan for the first time, and you aren’t happy with the plan, you’ll have spe­cial rights to buy a Medi­gap pol­icy if you re­turn to Orig­i­nal Medi­care within 12 months of join­ing.

• If you had a Medi­gap pol­icy be­fore you joined, you may be able to get the same pol­icy back if the com­pany still sells it. If it isn’t avail­able, you can buy an­other Medi­gap pol­icy.

• The Medi­gap pol­icy can no longer have pre­scrip­tion drug cov­er­age even if you had it be­fore, but you may be able to join a Medi­care Pre­scrip­tion Drug Plan (Part D).

For more in­for­ma­tion on Medi­care Ad­van­tage Plans, go to www. medi­care.gov.

Mike Zim­mer is pres­i­dent of Bay State In­sur­ance Agency Ltd. in Cen­tre­ville. He is avail­able to answer ques­tions or speak to groups re­gard­ing Medi­care, Medi­care Ad­van­tage, Medi­care Sup­ple­ments and Medi­care Part D (Pre­scrip­tion Plans). He may be reached at 410-758-1680.


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