Medicare Advantage Plans

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Medicare Advantage Plans

Since the 1970s, Medicare beneficiaries have had the option to receive their Medicare benefits through private health plans. Medicare Advantage plans, also called Medicare Part C are health insurance plans that are approved by Medicare and run by private insurance companies. A Medicare Advantage plan is required to provide all Medicare Part A and Medicare Part B benefits and may include prescription drug coverage.

Most Medicare Advantage Plans also add additional benefits like dental or vision coverage, health club memberships, medical transportation, or coverage for hearing aids. Although some require the beneficiary to pay a premium they are considerably lower than most Medicare supplements.

Diverse types of Medicare Advantage Plans

Health Maintenance Organization (HMO) Plans

In HMO plans, you generally must get your care and services from doctors, other healthcare providers, or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.

Preferred Provider Organization (PPO) Plans

Generally, you can get your healthcare from any doctor, other healthcare provider, or hospital in a PPO's network.

You can also go to doctors, other healthcare providers, or hospitals that aren't in the plan's network, but it usually costs more.

Private Fee-for-Service (PFFS) Plans

If you join a PFFS plan that has a network, you can see any of the network providers who have agreed to treat you. You can also choose an out-of-network doctor, other healthcare provider, or hospital that accepts the plan's terms, but it may cost more.

If you join a PFFS plan that doesn't have a network, you can go to any Medicare-approved doctor, other healthcare provider, or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will.

In an emergency, doctors, other healthcare providers, and hospitals must treat you.

Medicare Special Needs Plan (SNP)

Generally, you must get your care and services from doctors, other healthcare providers, and hospitals in the SNP network (except emergency care, out-of-area urgent care, or out-of-area dialysis). SNPs typically have specialists in the diseases or conditions that affect their members.

There are other less common types of Medicare Advantage Plans that may be available:

  • HMO Point of Service (HMOPOS) Plans: An HMO Plan that may allow you to get some services out-of-network for a higher cost.
  • Medical Savings Account (MSA) Plans: A plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your healthcare services during the year.

Remember, you still have Medicare if you enroll in a Medicare Advantage Plan. This means that you must still pay your monthly Part B premium (and your Part A premium, if you have one). Each Medicare Advantage Plan must provide all Part A and Part B services offered by Original Medicare, but can do so with different rules, costs, and restrictions that can affect how and when you receive care.

All Medicare Advantage Plans must include a limit on your out-of-pocket expenses for Part A and B services (for example, the out-of-pocket maximum for HMO plans in 2017 is $6,700). These limits tend to be high. Plans can’t include cost-sharing (copays or coinsurances) that are higher than they would be under Original Medicare for certain services, like chemotherapy and dialysis, but they can have higher cost sharing for other services. Medicare Advantage Plans can also provide additional benefits that Original Medicare does not cover, such as routine vision or dental care.

As noted above, diverse types of plans have different rules for how and where you can get coverage. However, even plans of the same type offered by different companies may have different rules, so you should always check with a plan to find out how its coverage works.

Medicare Advantage Plans often charge a premium in addition to the Medicare Part B premium. They also generally charge a fixed amount, called a copayment, that you are responsible for whenever you receive a service. Some plans charge a percentage of the cost of the service, called a coinsurance, for some or all services.

You can join a Medicare Advantage Plan if:

  1. You have Medicare Parts A and B;
  2. You live in the plan’s service area; and
  3. You do not have End-Stage Renal Disease (ESRD).
  • Note: If you have ESRD that requires dialysis or a kidney transplant, you can enroll in a Medicare Advantage Plan if you join a Special Needs Plan (SNP) that specifically accepts people with ESRD or if other unusual circumstances apply.

If you want Medicare coverage through a Medicare Advantage Plan and want drug coverage (Part D), you must generally choose a plan that offers Part D drug coverage as part of its benefits package. If you join an MSA, a PFFS without drug coverage, or a Cost Plan, you can join a stand-alone Part D drug plan.

Do the same type of Medicare Advantage plans work the same way?

No. It is important to note that lines can blur. Plans of the same type can, and often do, have different rules. For example, one HMO may require prior authorization for different services than another HMO, or may have stricter or looser network restrictions.

For the most part, each type of plan is characterized by a set of general rules about which doctors and other health providers you can use, when you can use them, and how much you will pay for your healthcare.

No matter what type of Medicare Advantage Plan you decide to join, make sure you know with the help of your Copeland agent, the specific plan’s network rules, restrictions, and costs.

How Medicare Advantage Plans work with your retiree insurance

Retiree benefits differ. You should check with the company providing you with retiree benefits before joining a Medicare Advantage Plan.

When you have retiree insurance, your Medicare Advantage Plan pays first, and your retiree coverage pays second. Depending upon the terms of your retiree health plan, it can pay your Medicare Advantage Plan co-pays and deductibles, and even provide additional benefits.

In some cases, you can only get your retiree benefits when you join a Medicare Advantage Plan with which your former employer contracts.

Be aware that if you switch to Original Medicare or enroll in a different Medicare Advantage Plan, your employer or union could terminate or reduce your health benefits, the health benefits of your dependents, and any other benefits you get from your company. Talk to your employer/union and your plan before making changes to find out how your health benefits and other benefits may be affected.

Copeland Insurance Agency is a leader in the sale of Medicare Advantage plans, which results in employees that are experienced in this unique product. In addition to our experience, we strive to offer the plans that provide our customers with the most benefits. The company requires agents to attend regular training to ensure our expertise in placing each of our valuable customers in the plan that best fits their needs.

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