Medicare Part C, or Medicare “replacement”, are alternate nicknames for Medicare Advantage plans. These plans are fairly comprehensive insurance policies which are designed to help seniors with Medicare coverage avoid the costly gaps in Medicare Parts A & B. Medicare Advantage basically replaces your federal Medicare benefits with a private health insurance policy, removing responsibility for your health care from the government, but protecting you from Medicare coverage gaps in return.
Federal Regulations for Medicare Advantage
Despite the fact that the government is less involved in Medicare Advantage, these policies still have to follow federal law. These laws protect seniors from being sold any less coverage than what they would normally get through Medicare. In addition to gap coverage, you may be eligible for ancillary benefits (which we will describe in more detail later).
Medicare Advantage Enrollment In Colorado
Colorado is yet another state in which Medicare Advantage has a popular following. Of all the Medicare-eligible Colorado seniors, 37% have a Medicare Advantage policy. The remaining 63% might be on an employer/group plan, have a Medigap insurance policy, or perhaps aren’t protecting themselves from Medicare coverage gaps at all. Among Medicare Advantage enrollees, enrollment in the different types of plans breaks down like this:
|Plan Type||Enrollment Percentage|
|Local PPO Plans||13%|
|Special Needs Plans||11%|
|Regional PPO Plans||9%|
|Private Fee-For-Service Plans||5%|
|Other (Cost Plans, MSA’s, etc.)||3%|
Plan Coverage & Cost
Prices for Medicare Part C will vary greatly depending on age, location, health status, and other important metrics which your provider will take into consideration. For a better idea of what you might pay, consult the chart for estimated quotes near you:
Most Popular Medicare Advantage Plans in Colorado
The Overall Star Rating system that Medicare uses to evaluate all companies offering Medicare related products and services, is a report based on information gathered by Medicare on each company. Typically, the report is issued annually usually around the open enrollment period. For companies providing health care, like Medicare Advantage plans, the Star Rating looks at how well the company utilizes preventive techniques like screenings and vaccinations, how well chronic diseases are managed, member experience with the company and changes in performance ratings, and customer service. The more stars the better the performance. You can use this report to help you evaluate a company you are interested in.
Helpful Medicare Advantage Tips & Tricks
Doctor/Provider Network Restrictions
When you are a member of a Medicare Advantage plan, you will not be permitted to get medical care outside of your preferred network of doctors and facilities (or if you do, it will be very expensive). In addition, your provider can change the rules at any time, suddenly restricting your access to the doctors and hospitals where you are an established patient. Be wary of this before you subscribe to a plan, and address any concerns you have with your insurance agent.
Where you generally need to get your care and services from for:
- HMO Plans: If you opt for a Medicare Advantage plan that is set up as a Health Maintenance Organization (HMO), the doctors and facilities you can use, including your primary care physician, specialists, hospital, surgery center, labs, etc., will be limited to those within the HMO network. Emergency or urgent care and out-of-state dialysis are exceptions to that rule. Some plans will offer a Point of Service (POS) plan with their HMO which will allow you to use a provider outside the network for a fee.
- PPO Plans: Preferred Physician Organizations also have networks, but unlike HMOs, there is no restriction on your choice of healthcare provider. If the provider you select accepts your insurance, the plan will cover you. However, be prepared to pay a higher copay for using a provider outside the network. Like an HMO, the network of PPOs is comprehensive and as a rule, you will save significant out-of-pocket expenses by using network healthcare providers.
- PFFS Plans: There are no restrictions on your choice of providers when you have a Private Fee For Services Medicare Advantage plan. If a provider will accept your insurance, your plan will cover you. However, many providers will not accept PFFS patients even if they accept Medicare patients. Payment schedules are typically low for providers. It is a good practice to confirm acceptance when making an appointment with a provider, even if they have accepted the coverage in the past.
- Special Needs Plans: Persons with chronic diseases or conditions, or are living in nursing homes, or qualify for both Medicare and Medicaid qualify for Special Needs Plans. If you are covered by a SNP your providers will likely be limited to those within Medicare’s SNP Network.
Finding a doctor who accepts your Medicare Advantage plan:
- HMO Plans: With an HMO you may, or may not, be able to choose your primary physician. In addition to being your personal doctor, this provider is responsible for directing you to other providers like specialists, labs, imaging centers, etc. within the network. Your plan requires that you use only healthcare providers and facilities within the network. Typically, emergency and urgent care and out-of-state dialysis are the only exceptions to the terms.
- PPO Plans: You will have the same freedom of choice with a PPO Medicare Advantage plan that you would a private health plan. You can see any doctor, hospital, or outpatient provider you wish, even if they are outside your preferred provider list, as long as you are prepared to cover your portion of the expenses, copays, and coinsurance costs.
- PFFS Plans: While PFFS plans have no restrictions on who you select to see, always check with the provider to determine if they accept your plan before receiving services. Many won’t. PFFS plans are known for offering low reimbursement plans to providers. Consequently, some providers will opt not to enter into a contract with them.
- Special Needs Plans: If you are in a SNP, your doctors will all be part of the Medicare SNP Network. The exceptions are emergencies that arise from accidents or a sudden onset of illness, or out-of-state dialysis.
Medicare makes finding a physician who accepts Original Medicare pretty easy thanks to their Medicare’s physician search tool. Most Medicare Advantage plans have similar online directories but it’s important to remember there may be some conditions.
Drug, Vision and Dental Coverage
Ancillary coverage, such as prescription drugs (a.k.a. Medicare Part D), vision, or dental – these are all options which can be bundled together into your Medicare Advantage plan. Many seniors believes that this convenience is worth the higher price that some providers charge. But it really all depends on your needs, and what you can afford.
- Often Medicare Advantage plans will offer benefits not provided by Medicare. Dental care is an example of those kind of services. Many Medicare Advantage plans have participating dentists who will provide routine dental exams including x-rays, cleaning, and filings. Other dental procedures like crowns, veneers, and dentures are not covered.
- Eye care is another service offered by many Medicare Advantage plans that is not available from Original Medicare. Typically, these benefits include an annual eye exam, lenses, glasses, and contacts. Check your plan’s directory to find participating vendors. Many will offer discounts to plan members on frames and other services.
Enrollment Options & Best Time To Enroll
Unlike a private insurance policy, you may not need to submit to a health screening or be asked questions about your health before your chosen provider will cover you with a Medicare Advantage policy if you enroll during open enrollment – even with pre-existing conditions. If you are basically healthy and relatively new to Medicare, you probably won’t have any problem getting coverage. But if you have a serious condition such as End State Renal Disease, it could get more complicated. For more information, consult your state insurance office, and take a look at our Medicare Advantage Enrollment Options page.
- Initial Enrollment Period: Within your first 6 months of Medicare enrollment, you can enroll in a Medicare Advantage policy.
- Annual Enrollment Period (AEP): From October 15th through December 7th each year, you are free to change or cancel your Medicare Advantage and part D drug plan.
- Special Enrollment Period (SEP): Any sort of special circumstance in which you may need to change or get new coverage outside of a regular enrollment period, such as moving out of your service area, losing your employer/plan coverage, or your provider ceasing coverage in your area.
What Medicare Advantage Plan Is Best For Me?
We think the best Colorado Medicare Advantage plan for you is one that you fully understand, has the medical staff and facilities that best serve your specific needs, and is affordable. It’s out there, you just have to find it. Be sure to check out the plan’s directory to ensure there are providers you have confidence in as members and that other facilities are conveniently located for you. If the plan offers Part D drug coverage, check the formulary to ensure the medicines you need are carried. Not all plans carry all drugs.
Premiums are important but with Medicare Advantage plans there are many zero-premium programs. Check copays for in and out of network services, deductibles, the company’s reputation and financial stability. If you do all that within the allotted enrollment period, we are confident you’ll find your perfect plan.