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Medicare Advantage Plans

Medicare beneficiaries often opt for enrolling in Medicare Advantage Plans (also often referred to as Medicare +Choice). These plans combine Hospital and Medical coverages into one insurance plan and may offer additional benefits beyond those available within Original Medicare.

Medicare Advantage Plans cover a wide range of hospital and doctor services. An important difference from the Original Medicare Plan is that with this option you get your benefits not directly from Medicare, but from private insurance companies which usually work under contract with Medicare. The nomenclature of services offered in Medicare Advantage plans reflects the benefits provided by the Original Medicare Plan. The benefits may also include preventive care, dental and eye health care, and even transportation to transfer you from one medical destination to the other. Some Medicare Advantage Plans offer Medicare Part D prescription drug coverage, but not necessarily. Other services provided by Medicare Advantage Plans may include medical savings accounts and managed care plans.

There are five general types of Medicare Advantage plans. The recent studies show that about 80% of Medicare Advantage beneficiaries are in Health Maintenance Organizations or in Preferred Provider Organizations. Both types of plans are aimed at delivering higher quality services than the Original Medicare Plan.

Medicare Advantage Health Maintenance Organization (HMO) usually covers hospital services including doctor and assistant services, skilled nursing facility, and hospice services. The promoted feature of this plan is an effective use of health care. The costs in HMOs are often lower than in Original Medicare.

This plan generally requires you to apply to the services of providers who belong to the plan's comprehensive network. Usually when you enroll in HMO plan you will have a primary care doctor who will attend to you and manage your health care needs. If you need to see a specialist, your primary doctor gives you a referral to one of the specialists within the plan's network. The allowable exceptions are the cases of emergency or out-of-the-area urgent care, and a pre-approved referral to a doctor outside the network.

If you want to see a doctor outside your plan's network, you may not use your Medicare benefits and generally have to pay out-of-pocket. This is the distinctive feature of HMO plans in comparison with other Medicare Advantage Plans (for example, Medicare Cost Plan), the Original Medicare Plan and Medigap policies. However, if you want to see specialists outside the network, some Health Maintenance Organizations offer a special Point-of-Service option to meet your needs. This service naturally involves extra costs. And if you are considering adding it to your policy, you should also know that your eligibility for the Point-of-Service option may be for a limited period only.

Some HMOs offer Medicare Advantage Prescription Drug Plans. You can choose whether to accept this option or to buy a stand-alone Prescription Drug Plan. At the same time you should remember that if your HMO does not offer Part D benefits, you cannot use a stand-alone Prescription Drug Coverage unless you are enrolled in Medicare Part D.

Medicare Advantage Preferred Provider Organization (PPO) operates under many rules of HMO. This plan allows you to pay less if you apply to doctors and hospitals indicated in your plan. Usually there is a network of providers who cooperate with a particular insurance company. But as a PPO enrollee you may use the services of other providers, though in this case you may incur additional medical costs. The good news is that PPO recipients usually have an annual limit on their out-of-pocket expenses which vary depending on the plan.

Generally you do not need a referral to see a specialist or any provider outside the network. If you choose to enroll in PPO, you are likely to get your Prescription Drug Coverage through your plan. To start your PPO coverage you should pay a deductible.

Medicare Advantage Fee-For-Service Plan (PFFS) allows you to apply for medical services to any providers who accept this plan's term and conditions of payment. The PFFS beneficiaries are not required to maintain a network of providers. Yet you should know that some doctors or hospitals may refuse to accept the terms and conditions of the PFFS plan if they work in conjunction with Original Medicare. Thus, if the plan's terms of participation and payment rates are those of Medicare, providers of PFFS can refuse to treat a patient any time they find the conditions unacceptable. With this plan you can have extra benefits which Original Medicare does not cover, such as extra days in hospital. Your PFFS plan may offer Medicare Prescription Drug Coverage but if it does not, you can join a separate Medicare Prescription Drug Plan. Beneficiaries' premiums, co-payments and deductibles are generally lower than in the Fee-for-Service system within Original Medicare.

Medicare Cost Plan (a type of HMO) allows you to apply to specialists or hospitals outside the plan's network, but in this case the Medicare services offered in Part A and Part B will be covered under the conditions set in the Original Medicare Plan, whereas the Medicare Cost Plan will pay for emergency services and urgently needed services beyond the Original Medicare domain. Many Medicare Cost Plans provide Prescription Drug Coverage. If your plan does not, you can get your Prescription Drug Coverage through a stand-alone Medicare Prescription Plan.

Medicare Advantage Medical Savings Account (MSA) covers your health care expenses (hospital and medical services from Part A and Part B) through a tax-free, interest-bearing bank account funded by Medicare. If you have spent all the money from your account there are two ways to cover health care services you might need. Unless you have reached the highest deductible you will have to pay out-of-pocket. If you have surpassed the fixed limit of your deductible, your plan will pay for all Medicare-covered services. This considered, Medical Savings Account Plans are usually subdivided into two parts:

A high-deductible Medicare Advantage MSA Health Plan covers your Part A and B benefits once you meet the plan's high yearly deductible; and

A Medical Savings Account is a bank account into which Medicare deposits money for you. You can use this money to pay for health care costs, including meeting the health plan's deductible. Any money you do not use will remain in the account and be added to Medicare's next deposit.

A significant feature of MSA plan is that you cannot enroll if you are already receiving the benefits of another coverage before your MSA plan's high deductible is met. Therefore, you should bear in mind that neither of the following insurance policies is compatible with MSA: Medicaid, Medigap, Employer Group Health Plan, Retiree Coverage, Veteran's Coverage, Federal Employee Health Benefits Plan.

It is also important to remember that an MSA does not include Prescription Drug Coverage. To receive this benefit, you need to enroll in a stand-alone Medicare Prescription Drug Plan.

On the whole, Medicare Advantage Plans are commonly regarded as an addition to the Original Medicare Plan and an alternative to Medicare Supplement (Medigap) Plans. If you are considering the options of Medicare Advantage and Medigap policies to meet your needs, you should keep in mind that if you have one of Medicare Advantage Plans (Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Medicare Cost Plans, Medicare Medical Savings Account Plans), Medigap policy will be redundant.

In order to join Medicare Advantage Plans you have to be Medicare Parts A and B beneficiary and to continue paying the required Part B premium. People with the end-stage renal disease do not qualify for Medicare Advantage Plans unless they already belonged to a Medicare Advantage Plan when they were diagnosed.

Most of the Advantage Plans require their own fixed monthly premiums for the additional benefits they offer. At the same time enrolling in a Medicare Advantage Plan usually proves to cut the expenses you would incur if you had to pay for the services out-of-pocket. In this sense thanks to a Medicare Advantage Plan you can have the protection you might need for your recovery. So, carefully compare premiums, costs of coverage and benefits offered. The chances are good that in the end you will opt for Medicare Advantage.



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