Topic: Medicare and Medicaid
There are two ways to obtain Medicare health benefits. With Original Medicare, which includes Part A (Hospital), Part B (Doctors and Diagnostics), and Part D (Prescription Drug), the government pays providers when you obtain health care. However, Medicare Advantage Plans, sometimes called “Part C” or “MA Plans”, are offered by private companies that are approved by Medicare. Medicare pays these companies a capitated monthly rate to provide your Medicare benefits. An Advantage plan will provide hospital, medical, and possibly prescription drug coverage under one plan. Advantage plans must cover all of the services that Original Medicare covers except hospice.
Although some Advantage Plans are fee for service, most are either a HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization). HMOs require you to go to doctors, hospitals, and other health care providers in the plan’s network, except in emergency situations. In addition, your primary care doctor acts as a gatekeeper and must refer you to specialists, other doctors, or for testing. With a PPO you pay less if you use health providers in the plan’s network, but if you see providers outside of the network it will cost you more.
You must have Medicare Parts A and B and live in the plan’s service area to be eligible to join. In addition to your Part B premium, you may have to pay additional plan premiums, deductibles, and co-pays, depending on the plan.
Plan benefits and coverage can change from year to year; therefore, it is important to review these before continuing with a plan for another year. You can change from and Advantage Plan to Original Medicare, or vice versa, during the Medicare Annual Enrollment Period, October 15 – December 7, each year.
[i] CMS Publication 11474, What is a Medicare Advantage Plan