People with a Medicare Advantage (MA) plan generally get all Medicare-covered services through the plan. These plans can include prescription drug coverage, MA-PD or be a MA-only plan. There may be a requirement to see certain doctors or go to certain hospitals to get their health care. Emergency care is covered anywhere in the United States. The benefits and cost-sharing may be different from the Original Medicare Plan.
Generally, the person with Medicare must still pay their Part B premium; however, some MA plans may pay all or part of that premium for the beneficiary. Some of the MA plans are offered at a zero premium, others plans may carry an additional monthly premium. The beneficiary will also have to pay other out-of-pocket costs—such as coinsurances or copayments.
Medicare Advantage Health Plans include:
- Medicare Health Maintenance Organization (HMO)
- Medicare Preferred Provider Organization (PPO) (Local & Regional)
- Medicare Private Fee-for-Service (PFFS)
- Medicare Special Needs Plans (SNP)
- Medicare Medical Savings Account (MSA)
Medicare HMOs are not available everywhere in Kansas. For the most part, you can find these plans in the Kansas City Metro area and Wichita. Because these plans operate with a Closed Network, it would be very difficult to offer HMO coverage in Rural Kansas.
The Network is the list of providers that will honor the HMO. A Closed Network simply means that if the beneficiary goes outside the Network for their services or supplies, the plan pays $0 and the beneficiary is responsible for 100% of their charges.
Often, these Medicare HMOs will be offered for a zero premium. This is often very attractive to beneficiaries, especially those on a fixed income. The person shopping for a Medicare Advantage plan, however, needs to look carefully beyond the zero premium. There could be other cost shares in the form of deductibles, copayments or coinsurances.
PPOs are available everywhere in Kansas. These plans operate with an Open Network.
An Open Network means simply that the beneficiary can go to providers (“preferred”) in the Network or the beneficiary can go to providers outside the Network (assuming that these providers are Medicare providers). The dollar difference with an Open Network? Going to a preferred provider, the plan pays the largest portion of the claim and the beneficiary pays a small percentage (coinsurance) or a small fixed rate (copayment, like $10). Going outside to a non-preferred provider, the plan pays less of the claim and the beneficiary is responsible for more of the claim.
This does give the MA member the option of seeing any doctor or provider that accepts Medicare. Most usually, there is no requirement for a referral to see specialist and the beneficiary does not need referral to see out-of-network provider or non-preferred provider.
PFFS plans are not always available in all areas of each state. These plans have no Network. However, there are some guidelines regarding the providers that a beneficiary can see. If a beneficiary is enrolled in a PFFS and in need of medical services or supplies, they first must be sure that the Medicare provider they want to use will accept payment from their PFFS plan. If the provider agrees to accept payment, they are called a “Deemed Provider.”
A Deemed Provider is a Medicare provider who has access to the information about the particular plan the beneficiary is enrolled in (phone, fax or computer) and agrees to the conditions of the plan. This can be on a case by case, person by person, visit by visit basis. This does mean that this insurance coverage goes anywhere in the United States—thus, no limit to the service area.
SNPs are designed to provide focused care management, special expertise of plan’s providers and benefits tailored to enrollee conditions. There are three types of SNPs and these plans may limit all or most of their membership to the people in the following three categories:
- Beneficiaries with certain chronic or disabling conditions
- Beneficiaries eligible for Medicare and Medicaid
- Beneficiaries who are in certain types of institutions
The Medicare Medical Savings Account (MSA) is comprised of two parts:
- Health Plan. The first part of a Medicare MSA Plan is a special type of high-deductible Medicare Advantage Plan. The plan will only begin to cover your costs once you meet a high yearly deductible, which varies by plan.
- Savings Account. The second part of a Medicare MSA Plan is a special type of savings account. The Medicare Advantage Plan deposits money into your account. You can choose to use money from this savings account to pay your health care costs before you meet the deductible.
Who can join? Anyone who qualifies—generally, beneficiaries with other types of health insurance are precluded from enrolling.
Cost sharing varies by plan; but it’s usually the same for in-network or out-of-network providers.
Generally, there is no premium for MSA plans but enrollees must still pay the Part B premium each month. Neither you nor your employer can deposit more money into the account. This deposit will be the same for every member of the plan, but different plans can set their own deposit amounts. The money in the account is meant to be spent on health care expenses. It will not be taxed as long as you use it to pay for “qualified medical expenses.”