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Advantage Plans

Medicare Advantage (Part C) Plans in Colorado

As we’ve mentioned, the main advantage of Medicare Advantage plans is that they limit the amount of money you have to pay out of your own pocket for health care.

Under most Part C plans, there’s a formal limit to how much you have to pay out-of-pocket each year for in-network medical services normally covered under Medicare Parts A and B. This limit is called the “maximum out-of-pocket amount for in-network medical services.” In Colorado, during 2012, the most you have to these services is about $3,800. (Under a POS plan that allows you more flexibility about the doctors or hospitals you choose, the out-of-pocket maximum is usually higher. In Colorado during 2012, it is about $8,000.)

An important note, related to out-of-pocket maximums: Once you’ve reached the maximum, most Colorado Part C plans prohibit providers from mixing in additional separate charges—sometimes called “balance billing”—that they send to you directly. This prohibition applies even if the plan pays a provider less than the provider charges for a service or if there’s some other dispute between the plan and the provider.

Another important note: To qualify for some Part C plans, you must be entitled to Medicare Part A and enrolled in Part B. Usually, the Part C plan administrator will help you make sure this “paperwork” is in order—but it’s important that you realize Colorado rules may require you to enroll in Part B even if you’re using a Part C plan.

If you choose a Part C plan, you will need to choose a network primary care provider (PCP), who oversees and coordinates your care. In most situations, your PCP must give you approval in advance before you can use other providers in the plan’s network—such as specialists (oncologists, cardiologists, etc.), hospitals, skilled nursing facilities or home health care agencies. This is called giving you a “referral.”

If you want or need more flexibility in choosing doctors, it’s important to shop around. In Colorado, some Part C plans—particularly PFFSPs and POS plans—operate on an “Open Access” basis, which means you do not need permission or a referral to see a specialist.