Medicare Advantage

What is Medicare Advantage?

We've put this section together to help answer some of your questions, but feel free to contact us with your questions.

Medicare Advantage Plans (also known as Medicare Part C) are health plan options that are part of the Medicare program. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. This coverage can include Medicare Part D prescription drug coverage or you can enroll in a separate Medicare Part D prescription drug coverage plan. Medicare Advantage Plans include:

• Medicare Health Maintenance Organization (HMOs)
• Preferred Provider Organizations (PPO)
• Private Fee-for-Service (PFFS) Plans
• Medicare Special Needs Plans (SNP)
• Medicare Medical Savings Accounts (MSA)

No health questions are asked. Acceptance is guaranteed for all Medicare eligibles every year during the appropriate enrollment period regardless of health conditions (except End Stage Renal Disease). Dual Eligibles -- people on both Medicare and Medicaid -- can enroll year-round. However, most Medicare Advantage plans require you to pay a co-pay each time you see a doctor, receive medical treatment, or visit a hospital. The maximum out-of-pocket expenses you are required to pay are often capped on a per-year basis, but not always.

When you join a Medicare Advantage Plan, you use the health insurance card that you get from the plan for your health care. In most cases there are extra benefits and lower co-payments than in the Original Medicare Plan. However, with PPO and HMO plans you may have to see doctors that belong to the plan or go to certain hospitals to get services or risk higher out-of-pocket expenses for going "out-of-network". PPFS plans enable you to see any health care provider that accepts Medicare assignment as well as the terms and conditions of the PFFS Plan.

To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer. Depending on where you live, some Medicare Advantage Plans have a $0 premium plan option, and some even reimburse you for part of your Medicare Part B premium. Some plans include dental and vision benefits in addition to coverage for hospital stays, doctor visits, diagnostic tests, inpatient and outpatient services, skilled nursing, and more. Some plans even include free health club memberships.

If you join a Medicare Advantage Plan, your Medigap (also known as a Medicare Supplement) policy won’t work. This means it won’t pay any deductibles, copayments, or other cost-sharing under your Medicare Health Plan. Therefore, you may want to drop your Medigap policy if you join a Medicare Advantage Plan. However, you have a legal right to keep the Medigap policy.

Original Medicare vs. Medicare Advantage

Medicare covers many of your health care needs. Today’s Medicare is working with private companies' health plans to provide different ways to get your health care coverage in the Medicare program. The Medicare health plan that you choose affects many things like cost, benefits, doctor choice, convenience, and quality. Your Medicare health plan choices include:

• The Original Medicare Plan – This is a fee-for-service plan that covers many health care services and certain drugs. You can go to any doctor or hospital that accepts Medicare. When you get your health care, you use your red, white, and blue Medicare card.

  The Original Medicare Plan pays for many health care services and supplies, but it doesn’t pay all of your health care costs. There are costs that you must pay, like coinsurance, copayments, and deductibles. These costs are called “gaps” in Medicare coverage. You might want to consider buying a Medigap or Medicare Supplement policy to cover these gaps in Medicare coverage. You can also add prescription drug coverage by joining a Medicare Prescription Drug Plan.

• Medicare Advantage Plans – Available in many areas. If you have one of these plans, you don’t need a Medigap policy. These plans include:

  • Health Maintenance Organizations (HMO)
  • Preferred Provider Organizations (PPO)
  • Private Fee-for-Service (PFFS) Plans
  • Medicare Medical Savings Account (MSA)
  • Medicare Special Needs Plans (SNP)

  These plans may cover more services and have lower out-of-pocket costs than the Original Medicare Plan. Some plans cover prescription drugs (these plans are known as, MA-PD for Medicare Advantage-Part D). In some plans, like HMOs, you may only be able to see certain doctors or go to certain hospitals to get covered services.

Medicare Advantage Enrollment

How do I get more information and enroll?
Enrolling in a Medicare Advantage Plan is easy. Call us at 941-492-4110 for a free Medicare Advantage quote and consultation. We can answer your questions and handle your enrollment entirely.

What is the Initial Coverage Election Period?
The Initial Coverage Election Period ICEP (not to be confused with the Initial Enrollment Period IEP for Medicare Part D) is a one-time event when an individual first has the opportunity to enroll in a Medicare Advantage (MA) plan. It occurs for most people when turning age 65 and enrolling in Medicare Parts A & B for the first time. This period begins three months before an individual is first eligible for both Medicare Part A and Part B, and ends on the later of:

1. the last day of the month before the individual is eligible for Parts A and B, or;
2. the last day of the individual's Part B initial enrollment period.
   The initial enrollment period for Part B is the seven month period that begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of eligibility.

The Initial Coverage Election Period for a Medicare Advantage (MA) enrollment election will frequently relate to either the individual's 65th birthday or the 25th month of disability, but it must always relate to the individual's entitlement to both Medicare Part A and Part B. When an individual enrolls in a Medicare Advantage- Prescription Drug (MA-PD) plan she/he used both the Initial Coverage Election Period and the Initial Enrollment Period (IEP) for Part D.

The Initial Enrollment Period for Medicare Part D Drug Plans (PDP) is the same as the Initial Enrollment Period for Medicare Part B (the seven month period that begins 3 months before the month an individual meets the eligibility requirement for Part B, and ends 3 months after the month of eligibility.

During the Initial Enrollment Period for Part D, individuals may make one Part D enrollment choice, including enrollment in an MA-PD plan. Individuals eligible for Medicare prior to age 65 (such as disability) will have another Initial Enrollment Period for Part D based on upon attaining age 65.

The Initial Election Coverage Period (ICEP) and the Initial Enrollment Period for Part D (IEP for Part D) occur together as one period when a newly Medicare eligible individual has enrolled in BOTH Part A and B at first eligibility. Should an individual delay enrollment in Part B to a later time, the ICEP and IEP become separate with the ICEP changing to then occur as the 3 months immediately proceeding entitlement to both parts A & B.

What is the Annual Election Period (AEP)?
The Annual Election Period for coverage effective in 2009 begins November 15, 2008 and ends December 31st, 2008. During this period, anyone who is enrolled in Medicare may enroll for the first time in a Medicare Advantage Plan plan; or change from one Medicare Advantage Plan plan to another; or return to Original Medicare from a Medicare Advantage Plan plan. If during this period you enroll in an Medicare Advantage Plan plan that includes Medicare Part D prescription drug coverage then any prior Medicare Part D Plan coverage is automatically cancelled and replaced by the new Medicare Advantage Plan plan with prescription drug coverage -- these plans are known as MA-PD plans (Medicare Advantage-Part D plans). Enrollments during this period have an effective date of January 01, 2009. The AEP occurs November 15 through December 31 of every year.

What is a Special Election Period (SEP)?
A Special Election Period means that you are allowed to enroll in Medicare Advantage after the IEP and/or AEP because you meet certain conditions set forth by the government. Below are the specific situations which might qualify you for a SEP.

You may qualify for a Special Election Period if:

• You are a Hurricane Ike evacuee and reside in certain zip codes as identified by the Federal Emergency Management Agency at the time of the hurricane (August 2008).
• You move permanently outside your plan's service area.
• You're enrolled in another prescription drug plan or a Medicare Advantage plan whose contract is terminated.
• You lose your previous creditable coverage through no action of your own.
• Your enrollment or non-enrollment is caused by an error by a federal employee or contractor hired by the federal government.
• You were eligible for both Medicare and Medicaid (a “dual eligible”) but you lost your dual eligibility status.
• You want to move from an employer-sponsored prescription drug plan to a Medicare Prescription Drug Plan.
• You want to leave your current Medicare Prescription Drug Plan because it was reprimanded by the federal government or the federal government has determined the plan violated a material provision of its Medicare contract in relation to services provided to you.
• You’re enrolled in a Cost Plan that isn’t renewing its contract with Medicare. This SEP begins 90 calendar days prior to the end of the contract year (i.e., October 1) and ends on December 31 of the same year.
• You want to move from a Program of All-Inclusive Care for the Elderly—PACE—to an MA-PD.
• You live in—or are moving in or out of—a skilled nursing facility, nursing facility, intermediate care facility for the mentally retarded, psychiatric hospital or unit, rehabilitation hospital or unit, long-term care hospital or swing-bed hospital.
• Your Medicare entitlement determination is made retroactively
• You are not eligible for premium free Part A and enroll in Medicare Part B during the Part B General Enrollment Period.
• You have a low-income subsidy.
• The federal government may authorize other special election periods.

Can I change my Medicare Advantage plan after I enroll?
Once enrolled in an MA or MA-PD Plan you can change your plan once between January 01 to March 31 of each year. If you want to change plans again you must wait until the next Annual Election Period (AEP) every year: November 15 - December 31.

What is the Open Enrollment Period (OEP)?
During the Open Enrollment Period (OEP) January 01 - March 31 an individual has the opportunity to make an MA election. During an OEP MA organizations are not required to open their MA plans for enrollment. However, because Original Medicare is always open during an OEP, an MA organization must accept valid requests for disenrollment during the OEP. MA eligible individuals may make one MA OEP election during the first 3 months of the year. A change of election made during an OEP is limited to the same type of plan in which the individual making the election is already enrolled. For example, an individual who is enrolled in an MA-PD plan may elect another MA-PD plan or disenroll from the MA-PD by enrolling in Original Medicare with coverage under a PDP. An individual who is in Original Medicare and is enrolled in a PDP may elect an MA-PD. However, the individual may not elect an MA plan that does not provide qualified prescription drug coverage.

An MA-eligible individual who is institutionalized, as defined by the Centers for Medicare & Medicaid Services (CMS), can make an unlimited number of MA elections during the OEP. Subject to the MA plan being open to enrollees an MA-eligible institutionalized individual may at any time elect an MA plan or change his or her election from an MA plan to original Medicare, to a different MA plan, or from original Medicare to an MA plan.

Some categories of beneficiaries are not bound by the lock-in rules and may enroll or disenroll from an MA plan in other than the ACEP or OEP. An individual may at any time, during a designated Special Election Period (SEP), discontinue the election of an MA plan offered by an MA organization and change his or her election to original Medicare or to a different MA plan. Examples of situations which may entitle an individual to an SEP include the termination or discontinuation of a plan, a change in residency out of the service area, the organization violating a provision of a contract or misrepresenting the plan’s provisions, or the individual meeting other exceptional conditions as CMS may provide. CMS has also designated an SEP for individuals entitled to Medicare A and B and who receive any type of assistance from Title XIX (Medicaid), including full-benefit dual eligible individuals, as well as those eligible only for the Medicare Savings Programs. This SEP lasts from the time the individual becomes dually eligible until such time as they no longer receive Medicaid benefits. Individuals who are eligible for an SEP under the guidance for Part D enrollment and disenrollment may use that SEP to also make an election into or out of an MA-PD plan.

from Medicare.gov, Glossary Definitions (Oct 2008)