Individuals with Medicare can obtain their medical care through original Medicare or the Medicare Advantage Program (Part C). Medicare Advantage Plans include HMO, PPO, Private Fee for Service Plans and Special Needs Plans. Of the more than 10 million individuals enrolled in Medicare Advantage Plans, the majority are enrolled in HMO’s (Health Maintenance Organizations) which have been available because the 1980’s.
To simply help your parents (or you) make an informed decision, they have to understand how these plans work, and then decide which plan is right for them. The following is really a brief description of each of the plan types.
If someone elects to opt for traditional fee for service Medicare, they are able to generally use any doctor or hospital that accepts Medicare assignment anywhere within the United States. However, Medicare does have deductibles, copays and cost sharing requirements that could play havoc with budgets. To simply help pay these additional out of pocket expenses, many individuals purchase Medigap or Medicare supplement policies.
Medicare Advantage Plans (Part C)
In the event that you opt to opt for a Medicare Advantage Plan, you actually trade your traditional Medicare benefits for these plans. Many of the Medicare Advantage Plans are given to eligible individuals at minimum cost besides continued payment of these Part B monthly premiums.
Medicare HMO’s (Health Maintenance Organizations)
These plans cover the same physician and hospital costs as traditional Medicare, but usually with lower out of pocket costs. HMO’s are attractive to Medicare eligible individuals since they often provide extra benefits like eyeglasses, hearing aids, and dental benefits that aren’t included in traditional Medicare.
Individuals considering a Medicare HMO should bear in mind that they’ll only receive medical services from providers who’re the main HMO’s network of contracted providers. The HMO usually requires an individual joining their plan select a principal care physician from those who participate in their network. This primary care physician would then be responsible for all medical care including referrals to a specialist and admittance to a hospital. The HMO will not pay for unauthorized visits to specialists nor non-emergency care received beyond your HMO’s service area or visits to non-network physicians.
These plans are private healthcare plans like HMO’s. However, PPO’s and HMO’s do differ into two extremely important areas. First, Medicare PPO’s do cover eligible medical care services obtained from doctors and hospitals beyond your PPO network. And, second, Medicare PPO’s do not usually require that you obtain an authorization before seeking care from a specialist.
Regional PPO’s can be purchased in many aspects of the country. These plans serve large geographic areas and must offer the same premium costs and plan benefits to any or all individuals residing in these areas. Medicare PPO’s cover the same kinds of medical expenses that traditional Medicare does. In addition, Medicare PPO’s commonly incorporate a prescription drug benefit. Unlike traditional Medicare, Medicare PPO’s have an annual out of pocket limit for benefits covered under Parts A and B of Medicare. The out of pocket limit caps the Myaarpmedicare amount someone can devote to covered medical expenses in a calendar year. As with any PPO program, when someone works on the non-contracted provider for covered services, they will pay more out of these pocket.
These plans are available to Medicare beneficiaries in exchange for their traditional Medicare Benefits. PFFS don’t have a conventional network of doctors and hospitals to choose from and not totally all doctors or hospitals are willing to supply medical services to participants in these types of plans. If someone is considering enrollment, it’s wise to check on with their doctor and local hospitals to be sure that they will accept the plan’s payment for services before enrolling. Also, the enrollee should thoroughly understand the advantages of a fee for service plan since the fee for service plans decide simply how much they will pay for Medicare covered services and may charge an increased cost sharing percentage than traditional Medicare. Private fee for service plans may incorporate a prescription drug benefit. If they do not, the enrollee is free to join a Medicare stand alone prescription drug plan.
These plans are private plans that offer benefits to Medicare beneficiaries, including prescription drug coverage, who need additional help paying for their medical benefits. These would include folks who qualify for both Medicare and Medicaid (MediCal in California), those residing in long haul care facilities, and individuals with chronic or disabling medical conditions.
Prescription drug plans are available to any or all Medicare eligible persons irrespective of medical history or income levels. Whenever a person first qualifies for Medicare, their initial enrollment period begins 3 months before their 65th birthday, includes their birth month, and ends 3 months after their birth month. Otherwise, the annual open enrollment period for prescription drug plans runs from November 15th thru December 31st, with the coverage commencing on the following January 1st.
Medicare drug plans are made to reduce drug costs for enrollees and protect against catastrophic drug costs. However, there’s a monthly cost for these plans. In addition to a monthly premium, the covered individual is required to pay a percentage of the expense of the medications (or a copay) and Medicare pays the main cost. Costs for an idea can vary with respect to the medications taken and the kind of plan selected. At least, the plans available must supply a “standard” level of coverage.