Medicare Advantage Plans
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Medicare is a federal health insurance program that pays most of the health care costs for people who are 65 and older. It also pays for health care for people who are eligible because of a disability or qualifying health condition.
Medicare Part A (hospital coverage) pays for
- in-patient hospital services
- skilled nursing facility care after a hospital stay
- home health care
- hospice care
- all but the first three pints of blood each calendar year.
Medicare Part B (medical coverage) pays for
- medical expenses
- clinical laboratory services
- outpatient hospital treatment
- preventive health services, including exams, lab tests, health screenings, and shots.
In most cases, Medicare pays 80 percent of the cost of approved medical expenses, including doctors’ services, medical equipment, and supplies. Medicare pays some Part B services at a set rate.
Medicare Part D (prescription drug coverage) pays for generic and brand-name prescription drugs. You can get prescription drug coverage either by joining a stand-alone prescription drug plan or by buying a Medicare Advantage plan that includes drug coverage. You probably don’t need Part D coverage if you’re in a group health plan that provides prescription coverage.
Only private insurance companies approved by Medicare may offer Part D coverage.
Most people get Medicare benefits through original Medicare. Original Medicare is sometimes called traditional Medicare or Medicare fee-for-service. You may go to any doctors or hospitals you want, as long as they accept Medicare patients.
Depending on where you live, you may be able to join a Medicare Advantage plan. Medicare Advantage is an alternative to original Medicare. If you join a Medicare Advantage plan, the plan will provide your Medicare parts A and B benefits. If you enroll in a Medicare Advantage plan, you are no longer in original Medicare but are still part of the Medicare program.
Medicare has contracts with insurance companies and managed care plans to offer Medicare Advantage plans in specific geographic areas. Medicare pays the plan a set amount each month, and the plan provides Medicare parts A and B services. Some Medicare Advantage plans require you to go to doctors in their networks.
Your out-of-pocket costs in a Medicare Advantage plan are different from what you would pay in original Medicare. You will continue to pay your monthly Medicare Part B premium, and you must pay any premium the Medicare Advantage plan charges. You will also pay any copayments, deductibles, and coinsurance the plan requires.
Medicare Advantage plans usually have more benefits than original Medicare. For instance, some Medicare Advantage plans may cover dental and vision services. Some Medicare Advantage plans include Medicare Part D. To get prescription drug coverage with original Medicare, you will have to buy a stand-alone prescription plan.
Medicare Advantage plans aren’t right for everyone. Consider your options carefully before joining a Medicare Advantage plan.
To join a Medicare Advantage plan, you must live in the plan’s service area, be enrolled in Medicare parts A and B, and usually not have end-stage renal (kidney) disease. A plan can’t drop you if you are diagnosed with end-stage renal disease while you are in the plan.
Each year, Medicare Advantage plans decide whether to stay in Medicare. Plans might also change the services or prescriptions they cover or increase their charges.
Your plan must tell you about any plan changes and costs for the coming year. You will get a separate notice if the plan ends coverage in your area. The notice will also explain your options.
If your plan ends, you may join another Medicare Advantage plan in your area or return to original Medicare. If you return to original Medicare, the plan must explain your options, including whether you have a right to buy a Medicare supplement insurance policy. Medicare supplement policies fill in the gaps between what Medicare pays and what you must pay out-of-pocket for deductibles, coinsurance, and copayments. If you had a Medicare supplement policy before you joined a Medicare Advantage plan, you might be able to get it back by going through the underwriting process.
The Medicare open enrollment period is the one time each year you can make changes to your Medicare Advantage plan. The Medicare open enrollment period is October 15 through December 7. If you make changes to your coverage during the open enrollment period, they will take effect on January 1.
During the open enrollment period, if you want to drop your Medicare Advantage plan and return to original Medicare, you must tell your plan in writing. If your plan includes medications, joining a prescription drug plan will automatically return you to original Medicare. If you switch from one Medicare Advantage plan to another, you will be disenrolled automatically from your old plan when the new coverage begins.
Prior to open enrollment, Medicare will mail you its Medicare & You publication. It has a list of all the Medicare Advantage plans and prescription drug plans available in Texas. You can also use the Find Health and Drug Plans feature on www.medicare.gov to see the available plans. The website is updated before October 15 of each year.
The Medicare Advantage disenrollment period is January, 1 through February 14. The disenrollment period allows you to leave your Medicare Advantage plan and return to original Medicare. You will not be able to buy a Medicare supplement policy or join a different Medicare Advantage plan during this disenrollment period.
If you disenroll from a Medicare Advantage plan, you have a right to enroll in a prescription drug plan, unless you already have a stand-alone prescription plan that was not part of your Medicare Advantage A plan.
You usually have to wait until the open enrollment or disenrollment period to switch plans. There are some exceptions, including moving out of the area or moving into a nursing home.
Read the Medicare & You publication for information about joining and switching plans. You may also call 1-800-Medicare. Medicare’s representatives can verify if you have a right to leave your current plan. If you do not have the right to leave the plan, use the appeal process to see doctors or to get prescriptions you need.
New Special Enrollment Period
Each year in October, CMS rates Medicare Advantage and prescription drug plans based on quality of care, access to care, responsiveness, and beneficiary satisfaction. Plans with the highest level of service are designated as 5-Star plans.
You may enroll in a 5-Star plan any time during the year, if a plan is available in your area. Your coverage with a 5-Star plan will begin on the first day of the month following your enrollment.
Once you've enrolled in a 5-star plan using a special enrollment period, you may only make changes during another special enrollment period or the annual enrollment period.
You can find a plan’s rating in the Medicare & You publication and online at the www.medicare.gov by clicking on Find Health and Drug Plans. The star-rating is the rating that allows a special enrollment period.
Medicare supplement insurance – sometimes called Medigap – fills in the gaps between what original Medicare pays and what you must pay out-of-pocket for deductibles, coinsurance, and copayments.
A Medicare supplement policy only works with original Medicare, not with a Medicare Advantage plan. If you drop a Medicare supplement policy to join a Medicare Advantage plan, you may not be able to get your Medicare supplement policy back if you later decide to return to original Medicare.
If your Medicare Advantage plan ends its coverage, you have 63 days to buy a Medicare supplement policy regardless of your medical history or preexisting conditions. This protection is called guaranteed issue. The plan you leave will give you information about your rights and options.
The Medicare Advantage options available in Texas include:
- managed health care plans, such as health maintenance organizations (HMOs)
- preferred provider organizations (PPOs)
- private fee-for-service (PFFS) plans
- Medicare special needs plans (SNPs).
Not all of these options are available in every county.
Companies must submit the Medicare Advantage and Part D plans they want to sell to the Centers for Medicare and Medicaid Services (CMS) for approval. Only companies licensed by the Texas Department of Insurance may offer plans in Texas. TDI monitors the companies and reviews consumer complaints against the plans.
If you have questions or concerns about Medicare Advantage or Part D plans, call your company or Medicare
Health Maintenance Organizations
Medicare HMOs usually require you to use doctors and hospitals they have contracts with. These doctors and hospitals make up the HMO’s "network” Some HMOs have an option called point-of-service that allows you to use doctors and hospitals who aren’t in the HMO’s network, but you’ll have to pay more.
You must also choose a primary care physician who will oversee your health care and provide referrals to specialists.
Preferred Provider Organizations
Like HMOs, PPOs contract with networks of doctors and hospitals. Unlike HMOs, PPO members don’t need a referral from their primary care physician to visit specialists or out-of-network doctors. However, your costs will be lower if you use the PPO’s network of doctors and hospitals. Some services may still require prior approval.
Private Fee-For-Service Plans
PFFS plans allow you to visit any doctor or hospital that accepts the plan’s terms of payment. However, some PFFS plans are required to have a network of doctors and hospitals. If the PFFS plan has a network, you will probably pay more if you see a doctor or hospital outside of the network.
You don’t have a primary care physician to oversee your care, so you don’t need a referral to go to a specialist. Although you must live in the plan’s service area to be eligible, you can receive treatment anywhere in the United States, as long as the doctor or hospital is willing to treat you.
Special Needs Plans
SNPs provide health care for people with specific diseases such as heart disease, diabetes, or other specialized needs. To be eligible for a plan, you must have a health condition covered by the specific plan. In some cases, you may have to change your doctor or hospital if yours isn’t willing to accept your plan. Some plans are specifically for people in long-term care facilities or for people eligible for both Medicare and Medicaid, also called dual-eligibles.
Begin by reviewing the advantages and disadvantages of Medicare Advantage plans in this publication. The Medicare & You handbook shows plans and their premiums, geographic coverage areas, maximum out-of-pockets costs, basic service costs, and medication lists if the prescription drug benefit is included.
Where you live will determine which plans you’re eligible for. The best way to choose a Medicare Advantage or prescription drug plan is to use the Find Health and Drug Plans feature on Medicare’s website at www.Medicare.gov. There are annual deadlines to pick a plan.
If you don’t use a computer or don’t have someone who can help you, call 1-800-Medicare and say "agent" when prompted.
You can also get local help by calling 1-800-252-9240. You will need your Medicare information, information about other insurance, the names of your providers, and list of medications you take.
Medicare Advantage Plan Costs
- Premiums. Medicare Advantage plan members must pay their Medicare Part B premium and usually an additional plan premium. Some plans may offer several premium options with different levels of benefits. Additionally, the cost for plans with prescription benefits will include the premium for the prescription plan.
Although the premiums for a Medicare Advantage plan may be less than that of a Medicare supplement policy, you also need to consider what your out-of-pocket costs are with the Medicare Advantage plan.
- Deductible. A deductible is an amount you must pay for medical services and prescriptions before your plan begins to pay. Once you meet your deductible, you will pay either a copayment or coinsurance.
- Copayments. Copayments are what you have to pay at the doctor’s office when you get medical care or treatment. Copayments for doctor’s visits usually range from $10 to $40, while copayments for emergency room visits are higher. If your plan covers prescription drugs, you’ll also pay a copayment for each prescription.
- Coinsurance. Coinsurance is the percentage of the cost of a service that you pay after the plan pays its portion of the cost. For example, a plan might pay 85 percent of the cost of a covered service, while you pay the remaining 15 percent. New rules for certain services limit what a Medicare Advantage plan can charge you.
- Extra charges. Some PFFS plans allow doctors and hospitals to charge you a remaining balance for the services you receive. It is in addition to the amount you pay in copayments or coinsurance, and you’ll have to pay it yourself. If you’re considering a PFFS, be sure to find out whether the plan allows doctors and hospitals to charge you and for what amount they can bill.
- Annual maximum out-of-pocket costs. Medicare Advantage plans must tell you about their annual maximum out-of-pocket costs. You can find the costs in the Medicare & You handbook and online. In addition, plans can’t charge more than what original Medicare would charge for services such as chemotherapy, dialysis, and nursing home care.
Services your plan denied because you didn’t follow a plan rule or you went out of network (other than for emergency care) don’t count toward the annual maximum out-of-pocket amount.
Compare estimates for out-of-pocket costs for different plans on the Medicare website.
If you have other insurance – such as a group retirement plan, Medicaid, or military retiree coverage-- find out whether the Medicare Advantage plan will work with it.
Also compare the costs and benefits of Medicare Advantage plans with your other coverage options. If you or your spouse is still working, you should be able to keep your coverage through the employer. Some employers extend this coverage to retirees as well.
Employer-sponsored group coverage is usually better coverage because it often includes benefits that Medicare does not cover, such as dental and routine vision care. Another advantage of maintaining group coverage is to cover a spouse not yet eligible for Medicare.
Note: Some employers may offer their retirees a Medicare Advantage plan that works with original Medicare. Ask your former employer about your benefits and options. A Medicare Advantage plan might cost less than a traditional plan. Like all Medicare Advantage plans, the plan will change each year. Make sure you ask for a member handbook to understand how your plan works. If you have problems or complaints, refer to your plan rules or ask your employer.
Advantages of Medicare Advantage Plans
- Cost if you rarely visit doctors. If you rarely have to go to a doctor, your out-of-pocket costs will generally be lower than if you enroll in original Medicare and buy a Medicare supplement policy. Some Medicare Advantage plans don’t charge a premium in addition to the Medicare Part B premium but will have deductibles, coinsurance, and copayments that you’ll have to pay. If you see doctors frequently, the plan may cost more even if you don’t pay a premium to the plan.
- Benefits. Medicare Advantage plans might provide more benefits than original Medicare. Some plans may also offer nonhealth benefits, such as transportation.
- Prescription coverage. Some Medicare Advantage plans with prescription drug benefits cover some prescriptions without a gap in coverage.
- Health history disregard. You can generally enroll in a Medicare Advantage plan regardless of your health history, unless you have end-stage renal disease. A Medicare Advantage plan can’t drop you if you are diagnosed with end-stage renal disease after you’ve joined the plan.
- Services under age 65. Medicare Advantage plans may offer more services, and at a lower cost, for people under age 65. People under age 65 who remain in original Medicare have fewer options for supplementing their Medicare coverage. Insurance companies in Texas are required only to offer Medicare Supplement Plan A to those under 65 and a beneficiary of Medicare.
Disadvantages of Medicare Advantage Plans
- Rules. Plans must tell you about their rules and how to receive services. Plans can legally deny payment for covered services if you didn’t follow their rules.
- Networks. Some plans require that you use their doctors and hospitals for all nonemergency care. Most plans also require prior authorization before covering certain services.
- Cost if you visit doctors regularly. A Medicare Advantage plan may not be the best option if you see doctors and hospitals frequently.
- Plan negotiations. Medicare Advantage plans negotiate contracts each year. Your plan could leave Medicare or change its benefits, premiums, and copayments at the end of each year.
- Dropping the plan. If you enroll in a Medicare Advantage or Medicare Part D plan outside of an annual enrollment period, you may not be able to drop the plan until the next year. If you dropped a Medicare supplement policy to enroll in a Medicare Advantage plan, you might not be able to get your Medicare supplement policy back. If you join a Medicare Advantage plan when you first enroll in Medicare Part B, your right to join a Medicare supplement policy lasts for one year.
If you need help comparing a Medicare Advantage plan with original Medicare or other options, call your local Area Agency on Aging (AAA) office. The AAA offices provide free one-on-one counseling about insurance and related issues.
Beware of deceptive and fraudulent Medicare sales practices. If you think you’ve been the victim of fraud, call 2-1-1 to talk to a benefit counselor and report the marketing fraud to Medicare
Medicare Advantage plans must give you a member handbook when you enroll. The handbook explains rules for getting services and information on grievances and complaints. It is important that you follow the complaint process within your plan. Similar to original Medicare, you have a right to several levels of appeal for a denial of services or for payment for services.
Here are some tips to help you protect yourself:
- Before joining a plan, always confirm with your doctor and hospital that they will accept the plan. Your choice of doctors and hospitals in a Medicare Advantage plan may be restricted. Don’t take a salesperson’s word for it!
- Don’t buy anything from a salesperson who comes to your home uninvited. It is illegal to sell Medicare Advantage plans door-to-door or to make unsolicited telephone calls. Plans may legally market by direct mail or through radio, TV, and print advertisements.
- Don’t be fooled if a salesperson claims to be with Medicare or Social Security, even if he or she shows you an official-looking identification card. Medicare and Social Security do not make home visits or unsolicited phone calls. An agent may not enroll you in a Medicare Advantage plan over the phone unless you placed the call to the agent or company.
- Be careful about giving out your Medicare number or other personal information. An unethical salesperson can use this information to illegally remove you from original Medicare and enroll you in a Medicare Advantage plan without your knowledge.
- Don’t sign anything you haven’t read and don’t fully understand. Agents are required to disclose in advance the product they are selling. Ask questions about things you don’t understand. Take notes. Write down the salesperson’s name, address, phone number, and what he or she told you. It’s a good idea to have a trusted friend or family member with you when you talk to the salesperson.
- Don’t believe a salesperson or agent who tells you that a Medicare Advantage plan won’t affect your original Medicare coverage. If you enroll in a Medicare Advantage plan, it will provide your health coverage instead of original Medicare. Some salespeople may try to tell you that Medicare Advantage plans are Medicare supplement insurance. They are not. Medicare supplement insurance fills in the gaps in original Medicare by paying some of the costs that original Medicare doesn’t cover. Medicare Advantage entirely replaces your original Medicare coverage. Your Medicare supplement policy will not pay benefits if you join a Medicare Advantage plan.
- Take your time to decide. Don’t buy anything from a salesperson who tries to pressure you into making a quick decision. Medicare offers online tools to help you learn about your options and find a plan that’s right for you.
- Verify that an agent and company are licensed. It is illegal to sell insurance in Texas without a license. To verify a license, call the TDI Consumer Help Line or visit our website
463-6515 in Austin
Understand your plan
Read your member booklet or evidence of coverage to know what services are covered and what out-of-pocket costs you will have to pay. Make sure you understand how the HMO or PPO handles regular appointments and visits to specialists. Keep the plan’s telephone numbers handy to call if you have questions.
Know how your plan covers emergency care, and ask how the plan handles ambulance charges if the condition was not an emergency. PFFS plans cover care anywhere in the United States as long as the doctor or hospital is willing to accept your plan’s payment terms.
All plans must pay for emergency care wherever you receive it. You are the judge of whether you’re having a medical emergency. Notify the plan as soon as possible if you receive emergency care. Review “Urgently needed care” that will be defined in your contract before you travel. You may also call the customer service phone number on the back of your member card.
Medicare Advantage plans must pay for any health care service that Medicare would pay for. You can ask the plan for an advance coverage decision to make sure a service is medically necessary and will be covered. If the plan decides a service is not medically necessary, you have the right to appeal the decision.
Know about leaving a plan
You may withdraw from a Medicare Advantage plan by notifying the plan in writing. If you leave a Medicare Advantage plan and had the right to switch plans, you will be automatically re-enrolled in original Medicare. You will be notified in writing that you are officially returned to original Medicare without any lapse in your Medicare benefits. You may also choose another Medicare Advantage plan instead of returning to original Medicare, if another plan is available in your area.
If you leave a Medicare Advantage plan and go back to original Medicare, you might want to consider a Medicare supplement policy to help pay for services that Medicare won’t cover. Some insurance companies sell Medicare supplement policies on a “guaranteed issue” basis. This means they will sell you a policy even if you have health problems. TDI’s Medicare Supplement Insurance Handbook and Rate Guide includes information on companies, rates, and policies. The handbook lists the companies that sell on a “guaranteed issue” basis. You can view the publication on the TDI website or call the Publication’s Order Line for a free copy.
Know what to do if your plan ends its Medicare contract. Your plan must give you notice if it intends to leave Medicare. If your plan leaves Medicare and you return to original Medicare, you have the right to buy Medicare supplement insurance regardless of your health. You must buy a policy within 63 days of the date your plan’s coverage ends. Your Medicare Advantage plan and Medicare will inform you of your options. Be sure to keep your final notification letter from the Medicare Advantage plan as proof that you are entitled to buy a Medicare supplement policy despite any health problems you might have.
Use the complaint and appeals process
If you are not satisfied with the care you received, first try to resolve the problem with your doctor or with the plan. If you have a question about a particular treatment you did or did not receive, ask your doctor for an explanation. If the plan denied payment for a treatment you received that you believe should be covered, look for statements in your plan’s evidence of coverage booklet that you believe support your position.
If you are still not satisfied, contact your plan’s customer service representative and file a complaint. If you feel the plan did not resolve your problem, call the local Area Agency on Aging
Know how to file an appeal
Federal regulations require Medicare Advantage plans to provide an appeal procedure for members. If you are denied medical services, or if a service is stopped, you have the same appeal rights as you do with original Medicare. Read your member booklet for details about the appeal process.
For answers to general insurance questions, for information about filing an insurance-related complaint, or to report suspected insurance fraud, call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website
463-6515 in Austin
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305-7211 in Austin
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The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.
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