Introduction to Medicare Advantage (Part C)

A Medicare Advantage plan is also called Medicare Part C, or a “replacement” plan. This type of insurance policy is designed to help individuals on Medicare cover the high costs of healthcare that they would otherwise be exposed to if they kept Medicare by itself—with no additional coverage. A Medicare Advantage plan sort of “replaces” Medicare in the fact that if you enroll in this type of policy—Medicare will no longer be the party directly responsible for paying your claims—but rather your Medicare Advantage plan provider will be the main party responsible for payment.

Federal Regulations for Medicare Advantage

Medicare Advantage plans are closely regulated by Medicare to follow a certain set of guidelines. Medicare mandates that Medicare Advantage plans must cover at a minimum what basic Medicare provides, plus the plan may add additional benefits on top. Some Medicare Advantage plans cover Part D as well, which is the prescription drug plan for people on Medicare. If you purchase a Medicare Advantage plan that includes drug coverage, they refer to this as a MAPD plan. Each company may offer different plans and benefits however, so it is important to shop around many carriers to ensure you have the best plan for your needs.

Medicare Advantage Enrollment In Ohio

Hundreds of thousands of individuals are covered by Medicare Advantage plans in Ohio. Approximately 35% of Medicare-eligible individuals choose a Medicare Advantage plan in Ohio, with the remaining 65% choosing another plan type, such as Medigap insurance. The chart below shows the approximate percentage of enrollment by plan type.

Plan Type Enrollment Percentage
HMO Plans 59%
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

Medicare Advantage plans range in price by state, county, and zip code, gender, age, height/weight, tobacco status, and possibly other factors. The chart below shows the different plan options and starting price point for each plan.

Most Popular Medicare Advantage in Ohio Plans

We decided to help seniors like you find the right plan by assigning each one an overall star rating. The more starts the plan gets, the better you can expect it to be. We look at all aspects of a potential plan, including how well they manage long-term care, customer satisfaction ratings, financial stability, and more. We also take the overall value of the plan into account when assigning a rating.

Helpful Medicare Advantage Tips & Tricks

Doctor/Provider Network Restrictions

When it comes to Medicare Advantage plans, you need to be careful about the network restrictions that your plan may have. Depending on the plan type and insurance company you choose, you may have many or few restrictions on provider access. As mentioned earlier in this article, there are a few most common plan types, such as HMO, PPO, and PFFS. HMO is the most restrictive plan type, while PPO and PFFS plan types give the consumer more freedom to choose the doctors they want. You will need to look at the network of each plan to ensure they cover the doctors you want. You should also consider the possibility of the doctor leaving the plan’s network and alternative options should this happen.

  • HMO Plans – Health Management Organizations tend to be more affordable overall, but they do limit you to one primary care physician and a small network of doctors and facilities you can get care from (if your primary doctor gives you a referral). The only time you can get care out-of-network and not have to pay full price out-of-pocket is in the event of an emergency.
  • PPO Plans – Preferred Provider Organizations are usually more expensive, but you have the freedom to get care from any provider at any time and get at least some of your expenses covered by your insurance company. The preferred providers are in-network doctors and facilities which your insurance provider will cover a greater cost share of if you get your care from them. If you get care from a doctor or facility that is not preferred,, you will have to pay more – but not 100% of the costs.
  • PFFS Plans – PFFS plans don’t have a network of approved doctors and facilities, per se. You can get care from anywhere or anyone at any time, but they must agree to your insurance company’s payment terms first. If they don’t, then you will have to pay the costs yourself. And just because one doctor agrees to the terms at your first appointment doesn’t mean they will necessarily still be on board during a follow-up appointment a few months later. So you’ll have to stay on top of things in order to make sure you’re getting your care from cooperating providers.
  • Special Needs Plans – Special needs plans help people who need lots of medical care for very specific, chronic diseases. These SNP Networks tend to be much more limited even than HMOs, but the doctors and facilities are hand-picked based specifically on your medical needs. Like an HMO, you will not be financially penalized from getting emergency care out of network; in all other cases, however, you will have to get permission from your insurance company if you want to get costs covered for out-of-network care.

Doctor/Providers List

  • HMO Plans – Unsurprisingly, HMo networks under a Medicare Advantage plan work the same way they would if you were still on a private insurance plan. This is true because, technically, you are under a private health insurance plan – but it’s a plan which must abide by the rules established by the federal Medicare program.
  • PPO Plans – PPO plans are very popular among Medicare Advantage providers. Since you require more care the older you get, it’s nice to have the freedom to see any doctor or get care from any facility you need whenever you need it without having to negotiate with your insurance company. Just keep in mind these plans may be a little bit pricier, even with the federal assistance you get from the Medicare program.
  • PFFS Plans – Yes, some Medicare Advantage plans have PFFS options. These plans give you the flexibility of a PPO but may leave you with fewer choices, like you would have with an HMO. You’ll still get all of the health benefits you would expect from a Medicare Advantage plan though, and they met be better equipped to negotiate prices and help you get care than a normal private health insurance company would be.
  • Special Needs Plans – SNP Medicare Advantage plans can help seniors with chronic illnesses like ESRD save a lot of money. You won’t have to pay 100% out-of-pocket if you need to get emergency medical care from a doctor or facility who is out-of-network. But you may have greater difficulty negotiating with your insurance company if you find yourself wanting to get care from someone who is outside of your network. It’s not impossible, though.

Are you worried about losing your doctor if you switch to a Medicare Advantage program? Then take a look at the search tool provided by the federal Medicare website. It can help you figure out which Medicare Advantage plans your current doctor is a part of, which should make the shopping process that much easier.

Drug, Vision and Dental Coverage

Medicare Advantage makes it easy to get vision coverage if you sign up for one of their plans. The vast majority of insurance companies which provide Medicare Advantage will give you the option to add vision coverage to your policy. That way, you can manage your health care and your vision care easily through the same company. Original Medicare and Medicare supplement insurance policies don’t typically offer vision coverage.

The same thing goes for dental insurance. Many Medicare Advantage providers offer dental coverage as an option; but Original Medicare and Medicare supplement insurance policies do not. From there, managing your dental care is simple – just pick a primary dentist near you who is in your insurance company’s network and you’re all set.

Enrollment Options & Best Time To Enroll

There are several enrollment options and ways to qualify for a Medicare Advantage plan. You may or may not be required to answer health questions, and pre-existing conditions also may or may not affect you. Generally the only health question required to pass in most states is whether or not you have End Stage Renal Disease (kidney failure). If you don’t have that you can generally qualify for coverage. However even if you have ESRD you can potentially qualify depending on your state and circumstances. To read more about the enrollment options below, please see our Medicare Advantage Enrollment Options page. It’s best to speak with a licensed agent to determine your exact eligibility and what plans are available to you based on your individual needs.

  • Initial Enrollment Period: 6-month timeframe when you first enroll in Medicare to purchase a Medicare Advantage plan.
  • Annual Enrollment Period (AEP): This timeframe runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
  • Special Enrollment Period (SEP): During special circumstances, you may be eligible to purchase/change a plan outside of the Annual Enrollment Period. Things such as moving out of the plans’ service area, losing group health or employer coverage, a company no longer offering plans in the area, etc. are all events that could trigger a SEP.

What Medicare Advantage Plan Is Best For Me?

You have a lot of important things to consider before you decide on a Medicare Advantage provider. The company has to be financially stable, well regarded by their customers, and effective at helping you manage your health care needs. You should also sit down and figure out what your future medical needs Maybe since you’re going to be with your Medicare Advantage provider for a long time.

Unfortunately, you don’t have very much time to make this important decision. The time could be ticking on your enrollment period as you read this. But we can help you make a smart decision quickly and easily if you compare quotes from different providers and shop around with us. If you still have any questions or concerns, we encourage you to reach out and contact us for clarification. We’ll be more than happy to help.

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