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3 Things To Know About Medicare Advantage

April 25, 2014
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By Martine G. Brousse

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At the beginning was Medicare. Called “straight” by billers, this Original Medicare (OM) consists of Part A (hospital, nursing, hospice) and Part B (physician care, labs, tests and Durable Medical Equipment). Part D (prescriptions) is available through commercial insurances.

Under OM, patient involvement is minimal. Medical providers provide services, bill and get paid within 14 days, a perfect example of the “Fee for Service” (FFS) process so much in the news lately. The Federal Government administers this single-payer plan.

Medicare Advantage, also called Part C, was introduced a few years ago to encourage competition and lower costs. Private insurance companies administer these diverse policies.

Medical offices often find senior patients misinformed about Medicare Advantage coverage. A lack of basic understanding may result in treatment delays, higher costs and added stress. Understanding three basic points will help you get appropriate and prompt care and avoid bad surprises.

1. Medicare Advantage is NOT Medicare (for medical providers)

Never assume or tell your doctor you have “Medicare” before checking your plan.

Once enrolled in a Medicare Advantage (MA) plan, you turn your Original Medicare benefits over to a private insurance company, which in turns provides coverage, administers your plan and pays your claims. You no longer have “Medicare” but the equivalent of a commercial policy, subject to its guidelines and limitations.

Ask any office if they accept “Medicare” — “yes” will probably be the answer. Ask about “Medicare Advantage” — “no” is more likely.

Why? Fewer providers hold MA contracts, due to a perceived inability to get timely or decent payments, and because of complicated paperwork and constraints. HMO plans can be especially burdensome and restrictive.

Under a MA plan, the “Medicare” administered by the federal government no longer pays your claims. Let the staff know before an appointment and use only the card issued by the private insurance carrier.

2. Conditions of coverage vary

Medicare Advantage (MA) plans are not based on the same easy “fee for service, get-paid-easily-as-long-as-you-followed-basic-and-well-publicized-guidelines” protocol used by Original Medicare (OM). They must offer the same coverage (doctor visits, in/outpatient services, emergency care, preventive services, tests and labs, mental health, some physical therapy, limited home or nursing care, hospice, some supplies and drug/alcohol treatments), but can offer additional services (vision, dental, hearing, part D).

There are 2 basic MA plans: HMO and non-HMO.


Patients must receive services through the HMO network exclusively. They are enrolled with a specific IPA (Medical Group) based on their area of residency and assigned to a PCP (Primary Care Physician) who oversees their overall care, refers them to specialists, and issues mandatory authorizations for services. Choice is reduced, as is access to specialists.

Part D must be purchased from the same HMO.

Non-HMO (also called FFS or PPO):

This type of plan, a misnomer, seems to indicate that the restrictions imposed by a HMO plan do not apply. However, your final liability may increase if your doctor is not contracted.

Because a doctor is in the PPO network does not mean he can accept MA patients. PPO plans are by definition commercial, therefore use caution when using the term “PPO” or “FFS” in the Medicare context.

Plan D can be purchased from a separate non-HMO insurer.

3. Possible (higher) share of cost

Many patients switch to an MA policy, only to discover they can no longer see their doctor or have unexpected costs.

While prescription discounts, lack of the standard 20% Medicare copay and a limit on the yearly share of cost could be great reasons to choose a MA plan, policies may have copays, deductibles and out of pocket costs higher than OM.

Although OM offers but a single policy, Medicare Advantage plans vary, as do commercial ones. Their monthly premium cost might be higher too.

In conclusion: 

Use the objective data and facts to compare Medicare Advantage plans. Visit the Medicare website for more details.

MA plans work well for a large number of patients, but doing some homework first remains advisable, as your choice will likely be locked in for a full 12 months.

Remember, you can join, switch or leave a MA plan during the Open Enrollment Period (mid-October to early December). You may join a MA plan anytime during the year only if the MA plan you choose has a 5-star rating, or if you have just become eligible. You may only drop out of an MA plan and return to an OM between January 1 and February 14 each year.