How does Medicare Advantage work?

ApexBlog - How does Medicare Advantage work?

Most of us are familiar with Original Medicare, also known as Medicare Parts A and B provided by the federal government. But what about Medicare Advantage, also known as Medicare Part C? Medicare Advantage works a little bit differently. The team at ApexHealth wants to help make Medicare easier to understand, so we decided to break things down further for you!   

How does Medicare Advantage work? Let’s dive in!

Medicare Advantage is another way to get your Medicare coverage. With a Medicare Advantage plan, private insurance companies like ApexHealth contract with Medicare, meaning we must follow the rules set by Medicare and submit our plans for review and approval each year. When you receive medical care, your Medicare Advantage plan is responsible for paying its share of the claims. Your Medicare Advantage plan also works with your doctors, hospitals and pharmacies on your behalf to ensure you receive the care you need to live life boldly.

What do Medicare Advantage plans cover?

If you enroll in a Medicare Advantage Plan, you’ll still have Medicare, but you’ll get most of your Part A and Part B coverage from your Medicare Advantage Plan. Most Medicare Advantage plans also include prescription drug coverage (Part D). These plans are known as Medicare Advantage Prescription Drug (MAPD) plans. Medicare Advantage plans may offer coverage for things Original Medicare doesn’t cover, including dental, vision and hearing plus additional supplemental benefits such as gym memberships and over-the-counter (OTC) allowances. Coverage varies by plan, so check with the plan before enrolling to see what benefits it offers.

What are the different types of Medicare Advantage plans?

There are several types of Medicare Advantage plans. Here are the four most common types:

1. Health Maintenance Organization (HMO) plans

Many HMO Medicare Advantage plans require you to have a primary care physician (PCP) – a doctor or other provider trained to give you basic care – to make sure you get the care you need to keep you healthy. Your PCP is the person you see first for health needs and can refer you to see specialists as needed. These plans (such as those offered by ApexHealth) have networks of health care providers, including doctors, other health care providers, hospitals, pharmacies and facilities. You’ll need to see providers in your network, except in cases of emergency. (We talk more about HMO Medicare Advantage plans in a previous blog post.)

2. Preferred Provider Organization (PPO) plans

PPO Medicare Advantage plans are like HMO plans in that you have a preferred group of doctors, specialists, and hospitals (provider network). However, PPO plans are different in that you may use providers outside the preferred network as long as the provider hasn’t opted out of Medicare. Your costs may be higher for out-of-network providers.

3. Private Fee-for-Service (PFFS) plans

PFFS Medicare Advantage plans are not the same as Original Medicare or Medigap plans. These plans work by determining how much the plan will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care. You may use any Medicare-approved doctor or service provider that accepts your Medicare Advantage plan’s payment terms and agrees to treat you.  

4. Special Needs Plan (SNP) plans

SNP Medicare Advantage plans provide benefits and services to people with certain healthcare needs, limited incomes or specific diseases. These plans tailor their benefits, drug list and provider choices to best meet the specific needs of the people they serve. There are three types of SNPs – Chronic Condition SNPs (C-SNPs), Dual Eligible SNPs (D-SNPs) and Institutional SNPs (I-SNPs).  

When can you sign up for Medicare?

You can first sign up for Original Medicare (Parts A and B) during your Initial Enrollment Period (IEP). For most people, this is the seven-month window which includes the three months before you turn 65, the month you turn 65, and the three months after you turn 65. (We go into more detail on the Medicare timeline in a previous blog post.) Once you’re enrolled in Original Medicare, you can enroll in a Medicare Advantage plan.

There are other scenarios worth noting for more information. Take a look and see if any of these apply to you:

If you’re feeling a little overwhelmed about all the Medicare enrollment details, let us help point you in the right direction. Check out our “Get your Medicare action plan” tool.

Do you still have questions about Medicare Advantage?

It’s okay – our ApexAssistants have answers… and lots of other information you might want to know. Give us a call at (844) 279-0508 (TTY: 711). Our hours of operation are Monday through Friday 8 a.m. – 8 p.m. (local time) from Apr. 1 through Sept. 30 and seven days a week 8 a.m. – 8 p.m. (local time) from Oct. 1 through Mar. 31.


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