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Medicare Advantage Plans
Choosing the Right Plan

Medicare Advantage plans, also known as Medicare Part C or Medicare managed care, are health plan options, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), approved by Medicare and run by private companies. Medicare pays these companies each month to provide all of your care. Anyone who applies with one of these plans during the appropriate enrollment period is usually accepted, including those people on Medicare due to disability. One exception would be an individual with end stage renal disease, or kidney failure. Enrollees will face a lock-in provision, meaning that once enrolled in a plan, you are in that plan until the end of the year before any change can be made.

These Advantage plans should not be thought of as supplemental insurance, and individuals who enroll in these plans do not lose their Medicare coverage. Medicare Advantage plans provide all of your Medicare Part A (hospital coverage) and Part B (medical coverage) benefits and must cover all of the medically necessary services that original Medicare covers. In addition, many of these plans provide additional services not available in original Medicare. Medicare Advantage plans can charge different copayments, coinsurance and deductibles for their services, including those which were covered by original Medicare.

Medicare Advantage plans generally have networks of providers. Some plans, usually HMOs, require that you must use only doctors, hospitals and suppliers who are part of this network in order to have these services paid for by your plan. Additionally, most plans require that you get a referral from your primary care doctor before seeing a specialist, even if that specialist is in your network. If you use providers that are not in your plan's network, you may have to pay the entire cost of the covered service.

Some plans, such as PPOs, allow you to use out-of-network providers, however you will likely pay higher copayments or coinsurance for these out-of-network services. Other plans, such as Private-Fee-For-Service plans (PFFS) or Medical Savings Accounts (MSA) have no networks or in the case of some MSAs, must allow you to use out of network providers. This does not necessarily mean that you can use any doctor or hospital you choose. The responsibility of ensuring that your doctor or provider will accept your plan lies with you.

With all this in mind, there are a few simple things to keep in mind before enrolling in any Medicare Advantage plan. First, consider whether or not you want to be limited as to which doctors or hospitals you may use. Do you spend significant amounts of time away from home, such as wintering in Florida, Arizona or some other warmer climate? If so, does your Advantage plan have network providers in that location? Emergency care must always be covered out-of-network, but routine services may not be.

Next, do you already have coverage, such as an employer plan or supplemental insurance that would be lost if you enroll in an Advantage plan? In most cases, persons enrolling in an Advantage plan will lose their current coverage when they join this new plan. Some plans will allow you to keep your current coverage, but not use it. Employer-provided coverage in particular can be VERY difficult to get back once you have dropped out. Consider these consequences before signing up for an Advantage plan.

"The best tip any potential buyer of an Advantage
plan can live by is to check all of the available
options. Do your homework! Do not be pressured
into buying or signing up with a plan on the spot!"

Do you see specialists? Your access to those specialists may be limited greatly when you join an Advantage plan. HMOs will require that you get referrals whenever you see a specialist, and copayments are generally higher to see these providers, even with a referral. PPO enrollment may require that you go out of network to see the specialist you choose, meaning higher copayments.

There are a few things potential buyers will want to do before signing with any plan. Ask to see a list of providers. Next, if your doctor and/or hospital of choice is on this list of providers, check with them to be sure they are accepting new patients with Advantage plan coverage. Surprisingly, some people have switched coverage only to find out their doctor isn't taking on any more patients with Advantage plans!

Always ask to see the Advantage plan's list of covered drugs if they are offering Medicare Part D drug coverage. You will want to be sure that the prescriptions you are currently taking will continue to be covered by your new plan. Additionally, if you are a member of Illinois Cares Rx, the state of Illinois prescription assistance program, not every Medicare Advantage plan will work with Illinois Cares. In order to get the maximum benefit, check with Illinois Cares to be sure the Advantage plan you choose will coordinate benefits.

Lastly, individuals can check with and compare Advantage plans available in their area. Our program, the Senior Health Insurance Program, can assist free of charge, any Medicare beneficiary, family member, or caregiver with doing this comparison.

The best tip any potential buyer of an Advantage plan can live by is to check all of the available options. Do your homework! Do not be pressured into buying or signing up with a plan on the spot; get the name of the plan, the agent making the sale, and check with Medicare, the SHIP program, or family members to make sure this is the best choice for you. Advantage plans can save you money, but joining a plan that doesn't meet your needs can be a very expensive mistake that is easily avoided with just a little research.

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