How Do Medicare Part C (Medicare Advantage) Plans Work?
What is Medicare Advantage?
Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are an “all in one” alternative to Original Medicare. They are offered by private insurance companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare
- • People who are 65 or older
- • Certain young people with disabilities
- • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant sometimes called ESRD)
Covered services in Medicare Advantage Plans
Medicare Advantage Plans cover all Medicare services. Medicare Advantage Plans may also offer extra coverage. Learn more about what Medicare Advantage Plans cover
Medicare Advantage Plans cover all Medicare services.Medicare Advantage Plans must cover all of the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. In all types of Medicare Advantage Plans, you're always covered for emergency and urgently needed care. The plan can choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered, check with your provider before you get the service. Most Medicare Advantage Plans offer coverage for things that aren't covered by Original Medicare, like vision, hearing, dental, and wellness programs (like gym memberships). Plans can also cover more extra benefits than they have in the past, including services like transportation to doctor visits, over-the-counter drugs, adult day-care services, and other health-related services that promote your health and wellness. Plans can also tailor their benefit packages to offer these new benefits to certain chronically ill enrollees. These packages will provide benefits customized to treat those conditions. Check with the plan to see what benefits are offered and if you qualify. 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. In 2020, the standard Part B premium amount is $144.60 (or higher depending on your income). 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. You (or a provider acting on your behalf) can request to see if an item or service will be covered by the plan in advance. Sometimes you must do this for the service to be covered. This is called an “organization determination.” If your plan denies coverage, the plan must tell you in writing. You don’t have to pay more than the plan’s usual cost-sharing for a service or supply if a network provider didn’t get an organization determination and either of these is true:
- • The provider gave you or referred you for services or supplies that you reasonably thought would be covered.
- • The provider referred you to an out-of-network provider for plan-covered services.
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 out-of-pocket costs
- Whether you need a referralto see a specialistA written order from your primary care doctor for you to see a specialist or get certain medical services.In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care rom anyone except your primary care doctor. If you do not get a referral first, the plan my not pay for the services.
- If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care
These rules can change each year.
Costs for Medicare Advantage Plans
What you pay in a Medicare Advantage Plan depends on several factors. Learn about these factors and how to get cost details
Costs for Medicare Advantage PlansWhat you pay in a Medicare Advantage Plan
Your out-of-pocket costs in a Medicare Advantage Plan (Part C) depend on:
- • Whether the plan charges a monthly premium. Some plans have no premium.
- • Whether the plan pays any of your monthly Medicare Part B (Medical Insurance) premium. Some plans pay all or part of your Part B 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; 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.
Get more cost details from your plan If you're in a Medicare plan, review the notices your plan sends you each fall:
- • "Evidence of Coverage" (EOC). The EOC gives you details about what the plan covers, how much you pay, and more.
- • "Annual Notice of Change" (ANOC). The ANOC includes any changes in coverage, costs, or service area that will be effective in January.
If you don't get these important documents, contact your plan.
Drug coverage in Medicare Advantage Plans
You usually get prescription drug coverage (Part D)
How to get prescription drug coverage
Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. This page explains how to get prescription drug coverage and offers tips for making the right choices for you.
If you decide not to get Medicare drug coverage when you're first eligible, you'll likely pay a late enrollment penalty if you join later, unless one of these applies:
- • You have other creditable prescription drug coverage
- • You get Extra Help
Generally, you'll pay this penalty for as long as you have Medicare prescription drug coverage.
To get Medicare drug coverage, you must join a Medicare plan that offers prescription drug coverage. Each plan can vary in cost and drugs covered.
2 ways to get prescription drug coverage
Medicare Prescription Drug Plan (Part D) These plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
Medicare Advantage Plan (Part C, like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.
How to join a drug plan
Once you choose a Medicare drug plan, here's how to get prescription drug coverage:
- • Enroll on the Medicare Plan Finder or on the plan's website.
- • Complete a paper enrollment form.
- • Call the plan.
When you join a Medicare drug plan, you'll give your Medicare Number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.
Consider all your drug coverage choices
Before you make a decision, learn how prescription drug coverage works with your other drug coverage. For example, you may have drug coverage from an employer or union, TRICARE, the Department of Veterans Affairs (VA), the Indian Health Service, or a Medicare Supplement Insurance (Medigap) policy. Compare your current coverage to Medicare drug coverage. The drug coverage you already have may change because of Medicare drug coverage, so consider all your coverage options. If you have (or are eligible for) other types of drug coverage, read all the materials you get from your insurer or plan provider. Talk to your benefits administrator, insurer, or plan provider before you make any changes to your current coverage.
Joining a Medicare drug plan may affect your Medicare Advantage Plan
Your Medicare Advantage Plan (Part C) will disenroll you and you'll go back to Original Medicare if both of these apply:
- • Your Medicare Advantage Plan includes prescription drug coverage.
- • You join a Medicare Prescription Drug Plan (Part D).
You can't have prescription drug coverage through both a Medicare Advantage Plan and a Medicare Prescription Drug Plan.
You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these are true:
- You’re in a Medicare Advantage Plan that includes drug coverage
- You join a stand-alone Medicare Prescription Drug Plan
How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans
Medigap policies can't work with Medicare Advantage Plans.
Medigap & Medicare Advantage PlansMedigap policies can't work with Medicare Advantage Plans. If you have a Medigap policy and join a Medicare Advantage Plan (Part C), you may want to drop your Medigap policy. Your Medigap policy can't be used to pay your Medicare Advantage Plan copayments, deductibles, and premiums. If you want 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, or in some cases, any Medigap policy back 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. Contact your State Insurance Department if this happens to you. 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 under federal law to buy a Medigap policy. You have these rights 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) . If you joined a Medicare Advantage Plan when you were first eligible for Medicare, you can choose from any Medigap policy. Some states provide additional special rights. For more information call your State Health Insurance Assistance Program (SHIP).
A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan’s terms and conditions, and thus may choose not to treat you, with the exception of emergencies.
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Let us help you navigate Wisconsin Medicare Advantage plans and options!
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"Or, please complete the following form, and submit your information. You will be contacted by one of our representatives to answer any questions and give you comparison quotes with several Medicare Advantage Insurance companies.
"We do not offer every plan available in your area. Currently we represent 10 organizations which offer 61 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options."