How to Pick a Medicare Advantage Managed Care Plan
Created by FindLaw's team of legal writers and editors | Last reviewed June 12, 2018
Medicare is a federally funded government health care program that helps pay for medical bills and prescription drug costs for people 65 or older and for certain disabled individuals. There are four parts to Medicare: Part A (hospital insurance); Part B (medical insurance); Part C (Medicare Advantage managed care plans); and Part D (prescription drug plan). Medicare Parts A and B are administered by the government, whereas Parts C and D are approved by the government but run by private insurance companies.
This article focuses on Part C -- called Medicare Advantage -- with tips on how to successfully choose a Medicare managed care plan.
Medicare Plans A, B, C, and D: Overview
Part A (hospital insurance) and Part B (medical insurance) are together what most people associate with traditional Medicare. Part A covers care in hospitals as an inpatient, critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas), skilled nursing facilities, hospice care, and some home health care.
You automatically get Part A when you turn 65 or begin taking Social Security benefits. You don't have to pay a monthly premium for Part A coverage because you've already paid into the system, through Medicare taxes, while you were working.
Part B (medical insurance) covers outpatient hospital care that Part A may not cover, such as physical therapy and some home health care, when they are medically necessary. Part B requires payment of a monthly premium ($134 as of 2018).
Medicare Advantage Managed Care at a Glance
In lieu of continuing to accept benefits from Medicare Parts A and B, you have the choice of enrolling in a managed care plan (Part C, called Medicare Advantage) through a privately run health care plan that combines the benefits from Medicare Parts A and B. While the government doesn't control the cost of Medicare Advantage, it does regulate who can enroll in the plan and when they can do so.
Medicare Advantage plans include managed care plans such as:
- Medicare Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPO)
- Private Fee-for-Service Plans
- Medicare Special Needs Plans
If you enroll in Medicare Advantage, you receive all of your Medicare benefits through the plan. You'll have to pay the monthly premium for Medicare Part B, and may have to pay an additional premium for the extra benefits the Medicare Advantage plan offers. Depending on your plan, it may or may not include a prescription drug plan.
The Pros and Cons of Medicare Advantage Plans
Medicare Advantage plans aim to curb the amount of co-payments and deductibles and fill in the gaps of coverage between Plan A and Plan B. As a result, those who enroll in Medicare Advantage don't need to purchase a Medigap insurance policy (which previously was the only way assure coverage for the gaps between Plan A and Plan B).
Advantages of enrolling in a Medicare managed care plan include increased coverage, decreased out-of-pocket costs, and, in many cases, the cost of Medicare Advantage prescription drug plans are lower than that of standalone Medicare prescription drug plans.
But be aware of several potential drawbacks to enrolling, which tend to vary widely by individual. These include:
- Potential limited choice of doctors;
- Extra step to be treated by specialists (must be referred by a primary care physician first);
- Geographic limits of coverage (especially for those who travel frequently); and
- plans may drop out of your geographic area if they're not profitable (remember, these are privately run plans).
Choosing a Medicare Advantage Plan: What to Look For
Keeping these advantages and disadvantages in mind, there are a few tips which you should follow or investigate when choosing your plan, or in deciding whether to enroll at all.
- Investigate the plan's network of doctors and providers - The network of doctors and other health care providers that the plan authorizes are set within the plan. Therefore, if you already have doctors and providers whom you trust and wish to continue seeing, you'll need to confirm that they are covered by the plan.
- Try to learn how difficult it will be to see a specialist - A vast majority of managed care plans require you to be referred to a specialist after first seeing a primary care physician. It could be frustrating when you clearly need to see a specialist but have to wait weeks to make an appointment to see your primary doctor first.
- Determine the plan's review process for claims - If you need a procedure or treatment that's declined by the managed care plan, you'll have to go through a review process that's outlined by the private plan, not Medicare itself.
- Explore other plan features which are important to you - Not all managed care plans are created equal. If treatments such as acupuncture chiropractic care, routine physicals, specific medical equipment or any other treatments are important to you, be sure to find a plan than covers all or part of it.
Need Help with Your Medicare Advantage Plan? Contact a Local Attorney
In the best-case scenario, choosing a Medicare Advantage managed care plan shouldn't require much hassle, or litigation for that matter. But complications sometimes arise, and you may have specific questions about the regulations and how they apply to you. If in doubt, contact an experienced health care attorney near you for some clarity.
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