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Facts to Medicare Advantage
Medicare Advantage is a unique alternative to Original Medicare coverage. Sometimes referred to asMedicare Health Plans, Medicare + Choice, or Part C, Medicare Advantage Plans are health plan options that are approved by Medicare and administered by private companies.Medicare Advantage Plans provide all of your Part A (hospital) and Part B (medical) coverage and mustcover medically-necessary services. Some plans offer extra benefits, such as dental and vision services.Medicare Advantage Plans also accept all Medicare beneficiaries, even those on Medicare due to adisability, and cannot have a waiting period for pre-existing conditions. The exception to this rule are thosewith End-Stage Renal Disease.
This web-page contains basic information about the various Medicare Advantage options in Nebraska.
Medicare Advantage Plans include:
Private Fee-for-Service Plans (PFFS)
Medicare Preferred Provider Organization Plans (PPO)
Medicare Managed Care Plans (HMO & POS)
Medicare Special Needs Plans (SNP)
Medicare Medical Savings Account Plans (MSA)
You must have Medicare Part A and Part B to join a Medicare Advantage Plan. Some plans do not charge a monthly premium, but you must continue to pay the Part B premium ($96.40 in 2008*).
If you are considering joining a Medicare Advantage Plan, keep the following in mind:
You are responsible for co-payments. Under Medicare Advantage, you must pay co-payments for:each Medicare-covered service, such as physician office visits and inpatient hospital stays. These co-pays vary according to plan.
Your provider may or may not accept your plan. Doctors or hospitals from which you receive care are not required to accept payment from Medicare Advantage Plans. If the provider does not accept the plan, you may be responsible for the entire payment. You may join a Medicare Advantage Plan when you first become eligible for Medicare, whether by age or disability. A seven month initial enrollment period is granted to new Medicare enrollees that includes the three months before your first month of Medicare eligibility, your month of Medicare eligibility, and the three months after your first month of Medicare eligibility. If you did not join when you were first eligible for Medicare, you can join between November 15 and December 31 each year. Your coverage will begin on January 1 of the following year.The Medicare Advantage open enrollment period is from January 1 through March 31 each year.
Beneficiaries may enroll, disenroll, or switch Medicare Advantage Plans once during this period, but
cannot join or drop a stand-alone Medicare prescription drug plan.
Under certain circumstances, you may be able to join a Medicare Advantage Plan at other times. Contact
the Nebraska Senior Health Insurance Information Program (SHIIP) at 1-800-234-7119 to see if you are
eligible for a special enrollment opportunity.
Those who are covered under Original Medicare may have a Medigap (Medicare supplement insurance)
policy. Medigap plans only work with the Original Medicare Plan, so if you join a Medicare Advantage
Plan, you do not need to keep your Medigap policy. If you are satisfied with your current Medigap policy,
you do not need to buy a Medicare Advantage Plan.
If you are over age 65 and were covered under Original Medicare and a Medigap policy, then joined a
Medicare Advantage Plan and cancelled your Medigap policy, you retain the right to cancel your Medicare
Advantage Plan during the first 12 months of enrollment and return to Original Medicare. If you do this
during the 12 month ıtrial period,ı you are granted a guarantee issue into the same Medigap policy in
which you were most recently enrolled, if available from the same issuer, or, if not so available, a benefit
package classified as Plan A, B, C, F (including F with a high deductible), K or L offered by any issuer.
If you are new to Medicare and elect to join a Medicare Advantage Plan, you retain the right to cancel your
Medicare Advantage Plan during the first 12 months of enrollment and return to Original Medicare. If you
do this during the 12 month ıtrial period,ı you are granted a guarantee issue into a benefit package
classified as Plan A, B, C, F (including F with a high deductible), K or L offered by any issuer.
Some Medicare Advantage Plans include coverage for prescription drugs. Extra help paying for
prescription drugs may be available if you have a low income and limited assets. Contact the Social
Security Administration at 1-800-772-1213 to find out if you qualify for extra help.
* The Medicare Part B standard monthly premium in 2008 is $96.40. Single beneficiaries with annual income greater
than $82,000 and married couples with annual income greater than $164,000 may have to pay a higher
premium.
Contact the Social Security Administration at 1-800-772-1213 for more information.
PRIVATE FEE-for-SERVICE (PFFS)
A Private Fee-for-Service (PFFS) plan is a type of
Medicare Advantage Plan. PFFS plans are offered
by private companies. The private company, rather
than Medicare, decides how much it will pay and
what you pay for the services you receive. Extra
benefits are often offered for an extra premium.
Enrollees do not need to choose a primary care
doctor. These plans do not have a ınetworkı of
providers. Beneficiaries can go to any Medicareapproved
doctor or hospital as long as the
provider accepts the planıs payment terms for
covered services. No referrals are necessary.
Monthly premiums may be lower, but
out-of-pocket co-payments may be higher than
when the beneficiary was enrolled in Original
Medicare and a standard Medigap policy.
Beneficiaries must continue to pay the Part A (if
necessary) and Part B Medicare premium ($96.40
in 2008).
PFFS plans must accept all Medicare
beneficiaries, even those on Medicare due to a
disability, and cannot have a waiting period for
pre-existing conditions. The exception to this rule
are those with End-Stage Renal Disease.
Some PFFS plans offer drug coverage. If the plan
in which you are interested does not offer drug
coverage, you can join a stand-alone prescription
drug plan in your area.
PREFERRED PROVIDER ORGANIZATION (PPO)
A Preferred Provider Organization (PPO) Plan is a
type of Medicare Advantage Plan offered in a
local or regional area. You should contact the plan
before you receive a service to find out if the
service is covered and how much it costs.
Enrollees do not need to choose a primary care
doctor. Beneficiaries can go to any Medicareapproved
doctor or hospital. PPOs have network
doctors and hospitals, but you can also use outof-
network providers for covered services, but
you will pay more than for services in-network.
No referrals are necessary.
PPOs limit your out-of-pocket costs but may have
higher premiums than other Medicare Advantage
plans. Extra benefits are often offered for an extra
premium.
Beneficiaries must continue to pay the Part A (if
necessary) and Part B Medicare premium ($96.40
in 2008).
PPO plans must accept all Medicare beneficiaries,
even those on Medicare due to a disability, and
cannot have a waiting period for pre-existing
conditions. The exception to this rule are those
with End-Stage Renal Disease.
You must get prescription drug coverage from the
plan. In Nebraska, all PPOs offer drug coverage.
MANAGED CARE PLANS (HMO & POS)
Managed Care Plans (HMO & POS) are a type of
Medicare Advantage Plan. These plans are only
offered in select Eastern Nebraska counties.
In most cases, enrollees must see a primary care
doctor to get a referral before you see any other
health care provider. If your doctor moves outside
of your coverage area, your plan will notify you to
choose another plan doctor.
HMOs have a network of providers. If you get
health care outside the planıs network, you may
have to pay the full cost of the services yourself.
If the plan has a Point-of-Service (POS) option,
you can go out-of-network, but you will pay more
than for services in-network.
Beneficiaries must continue to pay the Part A (if
necessary) and Part B Medicare premium ($96.40
in 2008).
Managed Care Plans must accept all Medicare
beneficiaries, even those on Medicare due to a
disability, and cannot have a waiting period for
pre-existing conditions. The exception to this rule
are those with End-Stage Renal Disease.
You must get prescription drug coverage from the
plan. In Nebraska, all Managed Care Plans offer
drug coverage
MEDICARE SPECIAL NEEDS (SNP)
In Nebraska, Medicare Special Needs Plans (SNP)
are Medicare Advantage Plans that provide
healthcare to three specific groups of people.
The first plan is available to individuals who have
both Medicare and Medicaid. These plans provide
access to coordinated, personalized care.
Beneficiaries who reside in a nursing home are also
eligible to enroll in a SNP. The plan supplements
nursing facilities services with an added layer of care,
including access to a Nurse Practitioner.
Finally, people with long-term illnesses including,
but not limited to, heart disease, asthma, high blood
pressure, and diabetes may also enroll in a SNP.
MEDICARE MEDICAL SAVINGS ACCOUNTS (MSA)
Medicare Medical Savings Accounts (MSA), introduced in 2006, have two parts. The first part is a highdeductible
Medicare Advantage Plan. The plan covers your healthcare costs once you meet a high yearly
deductible, which varies by plan. The second part of a Medicare MSA Plan is a special type of savings
account. Each year, Medicare deposits money into a bank account created by your plan. You can choose
to use money from this account to pay your healthcare costs, even before you meet the deductible.
Only Medicare-covered services are counted toward your planıs deductible. You may use the money in
your savings account for other expenses such as dental and vision, or even groceries and utilities, but these
expenses are not counted toward your yearly deductible. If you use all the money in your account before
your deductible is met, you will have to pay out-of-pocket for additional healthcare costs until your
deductible is met. After you reach your deductible, your plan will cover all Medicare-covered services.
Only your Medicare Advantage Plan can make deposits to your savings account ı you may not deposit
your own money. The amount of your deposit can change each year and may also earn interest. Any
money left in your account at the end of the year will remain in your account. If you stay with the
Medicare MSA Plan the following year, the new deposit will be added to any leftover amount.
You have access to the money in your account through a special debit or credit card. When you have a
medical expense, such as a fee for a doctor visit, you can pay for it using the card, and the money will
come out of your account.
In general, if you join a Medicare MSA Plan, you do not need other health insurance, such as a Medigap
policy. MSA Plans do not cover Medicare Part D prescription drugs, so you would need to join a standalone
prescription plan of your choice.
You may join a Medicare MSA Plan when you first become eligible for Medicare, whether by age or
disability. A seven month initial enrollment period is granted to new Medicare enrollees that includes the
three months before your first month of Medicare eligibility, your month of Medicare eligibility, and the
three months after your first month of Medicare eligibility.
If you did not join when you were first eligible for Medicare, you can join between November 15 and
December 31 each year. Your coverage will begin on January 1 of the following year. During this time,
you may also choose to leave a Medicare MSA Plan.*
There is no monthly premium for MSAs other than the Part A (if necessary) and Part B Medicare
premium ($96.40 in 2008). Contact the individual plan for more information on any of the benefits listed
on the following page.
* If you enroll in a Medicare MSA Plan for the first time and then change your mind, you can cancel your
enrollment by December 15 of the same year. Contact the plan to cancel your enrollment.
Please contact our office to see if a Medicare Advantage Plan is right for your health insurance needs.402.312.7997
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Copyright 2008 Advanced Health Plans Inc