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Medicare Advantage VS Original Medicare

Medicare Advantage plans from Peoples Health: get more than Original Medicare

Peoples Health Medicare Advantage plans offer all benefits covered by Medicare. Medicare Advantage plans are another way for people eligible for Medicare to receive coverage for medical services.

Medicare Advantage plans are regulated by the Centers for Medicare & Medicaid Services. While Medicare covers services received from any health care facility or any doctor who accepts Medicare, people who join a Medicare Advantage plan have a specific network of providers and hospitals from which they can receive services.

Members of a Medicare Advantage plan still pay their Medicare Part B premium, and they may pay a premium for the Medicare Advantage plan. Not all Medicare Advantage plans have a premium.

Medicare Advantage plans VS Original Medicare

Medicare Advantage plans usually offer coverage for more services, such as health club memberships, programs to help manage certain health conditions, and other “extra” benefits, such as routine vision care or preventive dental care.

Who is eligible to join a Medicare Advantage plan?

To enroll in a Medicare Advantage plan, a person must:

  • Be entitled to Medicare Part A and enrolled in Medicare Part B
  • Live in the plan’s service area
  • Not have end-stage renal disease (ESRD); however, there are certain instances when an individual who has or has had ESRD can still enroll

Confused about Parts A and B?
Learn more about the ABCs of Medicare.

How do Medicare and Medicare Advantage plans work together?

Medicare Advantage plans work with Medicare to provide coverage for health care benefits to people with Medicare. The plans must follow rules and standards set by Medicare. The federal government pays Medicare Advantage plans to provide all Medicare-covered benefits. If there is a difference between the amount a Medicare Advantage plan is paid by Medicare and the plan’s actual cost to provide benefits, the plan must use any savings to provide additional benefits or reduce costs for members of the plan. This is how some Medicare Advantage plans provide coverage for services such as routine vision care and routine dental care, which are not covered by Medicare.

Medicare issues quality ratings for Medicare Advantage plans. Medicare surveys people who join a Medicare Advantage plan to measure the overall quality of the plans, including quality of care, plan members’ ability to access care, plan responsiveness and member satisfaction. Individual Medicare Advantage plans are rated on a scale of one to five stars, with five stars being the highest score. Ratings are posted on Medicare’s website.

Dark blue circle with a prescription icon inside

What is a Medicare Advantage prescription drug plan?

A Medicare Advantage prescription drug plan is a Medicare Advantage plan that offers Medicare Part D prescription drug coverage as well as medical coverage.

What are the types of Medicare Advantage plans and Medicare Advantage prescription drug plans?

There are a variety of different Medicare Advantage and Medicare Advantage prescription drug plans, which are listed below:

Health Maintenance Organization

A health maintenance organization (HMO) plan covers care received from a specific network of doctors, hospitals and health care facilities. Members of an HMO plan generally must use these specified health care providers, and each member has a primary care physician.

Point of Service Plan

Some HMO plans have a point of service (POS) option, which lets people who join the plan see providers who are not in the plan’s network. Out-of-network services will usually have a higher cost to the member. Some services may require prior approval.

Preferred Provider Organization

A preferred provider organization (PPO) plan is similar to an HMO plan because it has a network of doctors, hospitals and health care facilities for plan members to use. Members of PPO plans also have the option to see providers who are out of network, although the member may pay higher costs for out-of-network services. Out-of-network services do not require prior approval.

HMO Special Needs Plan

An HMO special needs plan (HMO SNP) addresses the health care needs of individuals who meet any of the following criteria:

  • Are living in a long-term care facility or skilled nursing facility
  • Have severe or disabling chronic conditions
  • Are eligible for both Medicare and Medicaid

Employer Group Waiver Plan

An employer group waiver plan (EGWP) is an employee (or retiree) benefit plan established or maintained by an employer, an employee organization (such as a union) or a church group that provides medical care to employees and their dependents directly.

Private-Fee-for-Service

A private-fee-for-service (PFFS) plan is administered by an independent insurance agency. A PFFS plan differs from the other plans listed above because it allows plan members to go to any health care provider or hospital anywhere in the United States that agrees to accept the terms of the PFFS payment agreement. Members do not need referrals from primary care physicians to see specialists. However, members must make sure a provider accepts the plan’s payment terms prior to receiving any treatment.

Can I enroll in a Medicare Advantage plan if I have ESRD?

ESRD is a chronic condition due to temporary or permanent damage to the kidneys. This damage results in loss of kidney function that can eventually lead to renal failure.

People with ESRD are eligible for Medicare. However, under federal law, a Medicare Advantage plan cannot accept anyone who has ESRD unless the individual:

  • Can submit documentation that he or she received a successful kidney transplant and no longer requires dialysis
  • Began dialysis treatment for ESRD but recovered natural kidney function and no longer requires a regular course of dialysis to live
  • Developed ESRD while a member of a health plan offered by a Medicare Advantage organization
  • Developed ESRD after he or she signed the enrollment form but before the effective date of coverage
  • Is currently a member of a commercial health plan offered by the Medicare Advantage organization and wants to switch to another Medicare Advantage plan

 

A person with ESRD who was a member of a health plan that is no longer offered in the area in which he or she lives has a one-time option to enroll in another Medicare Advantage plan. A person who develops ESRD while enrolled in a Medicare Advantage plan may continue to be enrolled in that plan.

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