Government insurance can be a complicated insurance to navigate, but in its simplest form, you have two options. Your first option is to take the standard insurance with Part B and a drug plan. Secondly, you can take a Medicare Advantage plan offered by an outside insurance company who has a federal contract to offer you insurance.
Advantage plans (also known as MA plans) were introduced in 1997 by Bill Clinton. They were re-branded from Medicare+Choice being renamed Medicare Advantage, also known as Part C in 2003. Clinton wanted to give people more choice for their medical insurance and open up more doors to treatment.
What Are Medicare Advantage Plans?
MA plans are private plans offered by individual health insurance companies. CMS does not dictate to them or mandate what they will and won’t cover. The plans must offer the same basic things that non MA plans would, but beyond that, it is up to the insurer.
Regional and Inclusive
MA plans are regional and sometimes only usable in your zip code. The plans are most often all inclusive (some are not, but we will touch on that a little later on). The plans offer you most of the benefits you would get by going the traditional route, but there are also extras offered such as dental and vision which is not offered on traditional plans. Let’s break it down a little further.
Medicare Advantage Plan Explained
Say you are a 65-year-old man readying for retirement. Overwhelmed and inundated with calls and mailers advertising all the services offered to people entering the Autumn years.
After sitting down with an insurance sales agent, they give you the benefits, facts and choices for insurance coverage, which are:
– Traditional insurance with Parts A (hospital coverage) and Parts B (health insurance) (part B is also optional)
– A prescription drug plan (optional)
– MA plans plans with or without drug coverage (also called Part C)
– Supplemental Insurance
The only insurance you are required to have if you’re planning on drawing your SSA check is part A and that is free.
Furthermore, the sales associate explains you can’t have a traditional plan and an Advantage plan together, as a MA plan replaces traditional government insurance and farms your insurance coverage out to a private company.
After considering the options and benefits -and calling your doctor to make sure they accept the insurance- you enroll in an Advantage plan understanding that if you wish you can get off the plan only at certain times of the year when an enrollment period is available.
What Are The Requirements?
To qualify for a MA plan, you must meet the following conditions.
1. You must enroll in both Medicare part A and B
2. You must be 65 or older, under 65 and disabled or meet the requirements for a special needs plan
3. If you have ESRD (end stage renal disease) you may not qualify for a MA plan.
4. Be in a service area accepting new patients
It is important to note that these are the general guidelines, but most people will qualify for a plan. It is important to note that if you are signing up with a company you’ve had previously, you may have to pay them any outstanding balances owed and the first month’s premium before you can get coverage. CMS has no say in whether you can have a plan. You are signing up for a private health insurance plan, so what they say goes, period.
How Much do Medicare Advantage Plans Cost?
MA plans have a base cost of $144.60 which is the cost of the part B insurance and then you pay any additional to cover extras in the MA insurance policy. The fees differ, and there are some companies that will charge nothing more than the base payment for Part B (which comes out of your SSA check and is forwarded to your chosen insurance company to help administer your benefits)
How Are MA Plans Different to Non MA Plans?
With a traditional plan you do not have access or limited access to Dentists and Opticians. Original Medicare barely covers anything for those services. However, with MA plans, if they offer it, you can buy standalone vision and dental. Some companies have basic vision and dental in their plan. I stress that it is basic, so you can not be reliant on the “free dental” you must purchase add on plans if offered.
Prescription Drug Coverage
With prescription drugs, you have the choice to buy a plan with or without drug coverage. This is a tricky aspect to navigate and the medication that you take and the price charged for it will determine your choice. With traditional Medicare, they too offer standalone drug plans which have the same challenges.
In speaking about challenges, the big difference -and a bone of contention for many- is coverage, or where you can use the insurance. All Medicare patients face these challenges regardless of what insurance they have. The problem is that doctors can choose what insurance they take, or if they take insurance at all. Medicare and the Government do not, and can not dictate what insurance a healthcare worker will take so there can be difficulty in using the insurance.
In terms of difficulty, while it may be a benefit to have local coverage, this presents a problem when traveling. With traditional insurance you can use this wherever you want in the country- so long as the doctor accepts it. But with MA plans, they restrict you to one geographic area except with emergency -but you may have a higher out of network rate to pay.
What Are the Benefits of Non-traditional MA Plans?
MA plans have many benefits to offer the insured by offering the basic services not given by traditional insurance such as vision and dental and allow cheaper rates when going to the doctor. Also, most Advantage plans have copay rather than coinsurance so you know what you will have to pay before going to a clinic which is important if you are on a fixed income.
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