Medicare Advantage (Part C) Coverage

Medicare Advantage (Part C) is the type of Medicare coverage that often creates the most confusion for people enrolling in the Medicare system. This is, in part, because Part C coverage can be referred to by many names, including Medicare Advantage Plan, MA Plan, and just Part C. Another reason people are perplexed by Medicare Advantage Plans coverage is that there is more choice available to consumers than in any other type of Medicare coverage.

To understand Medicare Part C, you need to understand the structure of original Medicare. Original Medicare consists of Medicare Part A and Medicare Part B. Medicare Part A is hospital insurance. Medicare Part B is medical insurance (outpatient and doctor's visits).

Medicare Advantage plans coverage includes the coverage that is offered by both Part A and Part B original plans. However, it usually also includes prescription drug coverage (in place of Medicare Part D). These Part C plans can also provide coverage for dental, hearing, vision, and health and wellness care. MA plans are more like traditional medical insurance, such as HMO or PPO plans. This is primarily because they are offered by private insurance companies, which are approved by Medicare. With a Medicare Part C plan, you will usually have a deductible, copayment, coinsurance, and other costs associated with health insurance.

The specific terms and coverage will vary according to what Medicare Advantage plan you choose. However, Medicare Advantage plans coverage will include hospital inpatient stays, home health care, doctor's visits, hospital outpatient procedures, and more.

The terms of your MA plan and your Medicare Advantage plans coverage will depend first on the type of plan you choose, and then on the specific plan.

Types of Medicare Advantage Plans Coverage

There are six types of Medicare Part C plans. The first four are more common, while the last two are fairly rare. The insurance companies which provide MA plans are private companies. This means that they determine what plans they will offer and in which areas or states those plans are made available. It is important to check and see if the plan you are considering is available to you.

1. HMO: Health Maintenance Organization

Your HMO care is centered on a primary care physician (PCP) which you choose from a list of network providers. If you need to see a specialist of any kind, you must have a referral from your primary care physician. This includes lab tests, x-rays, and other diagnostic tools.

2. PPO: Preferred Provider Organization

Another form of Medicare Advantage plans coverage is a PPO plan. Preferred provider organizations offer more freedom to the patient. The insured can choose a physician from in-network providers. They do not need to choose a primary care physician or get a referral to see a specialist. An out-of-network doctor may be seen, but the patient will typically have to pay a higher amount and the entire bill out of pocket, and then be reimbursed after turning in receipts.

3. PFFS: Private Fee-For-Service Plan

With a private fee-for-service plan, the services covered by Medicare plans have established fees. The health care provider contracts to accept the fees set forth by the insurance company. The patient should always ask if the physician will accept the fee terms before accepting treatment, except in the case of an emergency. Emergency services are covered even if the provider does not contract with the PFFS company.

4. SNP: Special Needs Plan

Special Needs Plans help to save patients money by targeting the specific Medicare Advantage Plans coverage necessary for unique groups of people. These plans are available to groups of people who have a disease, condition, or characteristic in common. These are typically chronic conditions, such as heart disease, AIDS/HIV, diabetes, end-stage renal failure, and mental disorders.

5. HMOPOS: Health Maintenance Organization Point of Service Plan

An HMO Point of Service plan merges some of the qualities of a PPO into an HMO environment, to allow for more choice and freedom for the patient. These can potentially provide a great amount of Medicare Advantage Plans coverage, as the plan normally pays for all (or almost all) services. There is a primary care physician, but patients can go out of network if their PCP refers them to that specific doctor.

6. MSA: Medical Savings Account Plan

Health plan meets savings account is the recipe for the Medical Savings Account Plan. An MSA plan is designed around a high deductible. The patient and the Medicare system put the Plan B premium (and sometimes more) into a specified Medical Savings Account to cover medical costs throughout the year. This gives more control to the patient, but there is a higher deductible to be met before the health care plan pays for services.