Private companies contract with Medicare to offer coordinated care and private fee-for-service health insurance plans. Medicare pays these plans, which all use some form of managed-care techniques, to provide all of your Medicare-approved services. When you join a Medicare Advantage (MA) plan, you agree to that plan’s terms and conditions.
- You will receive the same benefits as in Original Medicare, but not at the same payment rates.
- You will still pay the Part B premium, plus a premium to the plan (unless the plan has a $0 premium) and co-payments or co-insurance for certain services.
- Medicare Advantage plans may offer additional coverage, such as routine preventive vision or dental.
- Where you live (based on your ZIP code) often determines which Medicare Advantage plans are available to you.
- Most people who have Medicare Part A and Part B and live in the plan’s service area can join a plan.
Note: Beneficiaries with End-Stage Renal Disease (ESRD) are not eligible to join a plan. However, if you are already in a plan and develop ESRD, you may stay in the plan. If you’ve had a successful kidney transplant, you may be able to join a plan.
Medicare Advantage plans renew their contracts annually with the Centers for Medicare and Medicaid Services (CMS). This means the policies are not guaranteed renewable. However, if you join a plan and that plan decides to not renew its contract with CMS, you have protection under the law that enables you to join another plan or purchase a Medigap policy.
You may join, leave, or switch Medicare Advantage plans during your Initial Enrollment Period (IEP) when you are new to Medicare, or during the Annual Enrollment Period (AEP), Oct. 15 to Dec. 7, also referred to as “Fall Open Enrollment.” The Medicare Advantage Disenrollment Period (MADP) happens from Jan. 1 through Feb. 14 every year.
The common Medicare Advantage plan types available in Oregon:
- HMO—Health Maintenance Organization
- HMO-POS—HMO with Point-of-Service option
- PFFS—Private Fee-for-Service plan
- PPO—Preferred Provider Organization
- SNP—Special Needs Plan
If you want to switch from one Medicare Advantage plan to another Medicare Advantage plan, simply enroll in your new plan during the AEP Oct. 15 – Dec. 7. You will be automatically disenrolled from your old plan.
Ask the business office of your doctors and hospital if they are in the network for a plan you are considering. Even though a plan may be offered in your area, providers do not have to participate. In some plans, if your doctor is not part of the preferred network, you will have to pay more to see that doctor. It is very important to know if the plan you’re considering includes your doctors and hospital of choice. And get this information for yourself—Internet web sites and printed materials can be incorrect and an agent wanting to sell you a plan may be misinformed.
Make sure you understand the coverage, including premiums and co-pays, for any Medicare Advantage plan you’re considering. The plan description pages list your share of the costs. Here are some of the key terms you’ll want to understand:
- Premiums: The amount you pay monthly for a plan. In a few cases there is a $0 premium.
- Maximum out-of-pocket costs: This is the most you would have to pay in a year for covered services, excluding Part D drugs, before the plan starts paying 100 percent. Not all covered services may count toward the out-of-pocket maximum.
- Co-pays: A fixed amount you pay for a service.
- Co-insurance: A percentage of costs you pay for a service.
Most HMO/PPO plans include integrated prescription drug coverage (MAPD). Your drug coverage must be this “bundled” package. Exception: If you have VA drug coverage available, you can use it with the health-only MA plan, if the plan allows it. PFFS plans allow you to choose a stand-alone prescription drug plan or enroll in their combined MAPD.
Note: Original Medicare does not cover routine dental care. Some Medicare Advantage plans may be like Original Medicare and not cover dental care. Other MA plans choose to cover preventive care, such as cleanings and X-rays, up to a capped limit.