Medicare Advantage (Part C)

What are Medicare Advantage Plans?
Though it is a different ‘part’ of Medicare, Part C or Medicare Advantage is a method for beneficiaries to receive their standard Medicare benefits (Parts A and B) through a private carrier, possibly with additional benefits and/or costs. The federal government pays each Advantage plan a monthly amount to provide the same care as Original Medicare. Medicare Advantage plans may offer additional benefits as well.

There are seven types of Medicare Advantage Plans available in Colorado. Each operates differently in terms of networks, coverage and cost.

  • Health Maintenance Organizations (HMO): Requires individuals to receive inpatient, outpatient, home care, nursing care, pharmacy benefits, and durable medical equipment from the plan’s network of providers. Individuals are required to have a primary care physician. A referral is required to see a specialist. In emergencies, service can be administered by the nearest care provider. Benefits may include things like vision, dental or wellness programs. Most plans offer prescription drug benefits. There is an annual limit on out of pocket expenses. May require higher co-payments or referrals to see specialists or out-of-network providers. Individuals who receive care (other than emergency care) from providers outside of the network will pay the providers “full” usual and customary costs. None of the costs will be covered by the HMO.
  • Cost Medicare Advantage Health Plans (Cost HMO): Uses the same rules are HMOs, however if a beneficiary goes to a provider outside the network, the individual pays the Parts A and B co-pay and deductibles. Individuals may pay a higher additional co-pays as well. Benefits may include things like vision, dental or wellness programs. Most plans offer prescription drug benefits. There is an annual limit on out of pocket expenses. This offers greater flexibility than straight HMOs, but individuals are required to have a primary care physician. Co-pays are less if the individual sees a specialist with a referral from the primary care physician; but a referral is not required. There is an annual limit on out of pocket co-pays.
  • Preferred Provider Organization Plans (PPO): Similar to HMOs, but beneficiaries can see any doctor or provider that accepts Medicare. Individuals do not need a primary care physician. Referrals are not needed to go out of the network. May pay higher co-pays for specialists or other providers without a referral.May include things like vision, dental or wellness benefits. Most plans offer prescription drug benefits. There is an annual limit on out of pocket expenses.
  • Medicare Special Needs Plans (SNP): Individuals who are institutionalized, frail or needing special services in the community can enroll in SNPs if they are available in the service area. The SNP receives higher reimbursement rates from Medicare and in turn often can offer additional services to those offered by original Medicare, like transportation, care management and dental services. All SNPs must offer prescription drug coverage.The individual must have a primary care physician. Usually a referral is needed to see a specialist, except in cases like screening mammograms which do not require a referral.
  • Private Fee For Service Plans (PFFS): Offers the same coverage as Original Medicare, but beneficiaries can go to any provider who is willing to accept the plan’s terms of payment. All PFFS plans have a provider network, and some may charge extra to go to out of network providers. Since the plan decides how much to pay the providers, some providers who are not in the network may not treat beneficiaries; or they may treat the beneficiary for a one-time only visit. All providers must accept the payment for emergencies. May have extra benefits such as vision, hearing and wellness programs; but will also have variable deductibles, co-payments and may allow balance billing above Medicare approved amounts. PFFS plans may offer drug coverage. Individual does not need a primary care physician or a referral to see a specialist.
  • Point of Service Plans (POS): Similar to HMOs, but offer some services out-of-network for additional costs. As of 2011, only Kaiser Permanente offers a POS plan in Colorado. This is a plan that allows individuals who leave the service area for extended periods of time to be able to continue to receive health care, i.e., if an individual lives in Denver and wishes to reside in Arizona for the winter months, this is an option to continue to receive health care benefits through Kaiser. Other requirements like having a primary care physician and needing a referral to see a specialist are the same as an HMO.
  • Program for All-Inclusive Care for the Elderly (PACE): Using a day program as the central service for delivery of care, a team of physicians, nurse practitioners, therapists and other specialists use an interdisciplinary approach to delivery care in the home, assisted living or nursing home. In Colorado, this is only available in Metro Denver, Colorado Springs, Pueblo, and Montrose at this time.

How to enroll in a Medicare Advantage Plan
All Medicare beneficiaries may enroll or disenroll from Medicare Advantage Plans during the Open Enrollment Period from October 15 to December 7 every year, or during their Initial Enrollment Period (three months prior to, the month of, and three months subsequent to the individual’s date of Medicare eligibility). Coverage is effective from January 1 of the following year. You must be already enrolled in Medicare Parts A & B prior to the Open Enrollment Period if you did not enroll when you were first 65.

Beneficiaries may receive a Special Enrollment Period if they permanently move to a new service area and lose coverage (you have 63 days to choose a new plan), or if they have both Medicare and Health First Colorado (Medicaid) (can change monthly), or if they move in or out of an institution such as a nursing home or hospital.

Individuals can disenroll by notifying the plan in writing, by phone or by calling 1-800-MEDICARE. Disenrollment will be effective the first of the month following the notice. Disenrollment can also occur for non-payment of premiums after 120 days.

Choosing a Medicare Advantage Plan
Companies offering Medicare Advantage Plans must have them approved annually for sale in certain service areas. All plans may not be available in all areas.

When choosing an Advantage Plan, it is important to consider the network of physicians and specialists, nursing homes, home care agencies, hospitals, durable medical equipment providers and pharmacies to ensure the providers will meet your needs. Beneficiaries should review the formulary for prescription drugs to determine if the drugs they currently are taking are on the formulary and possibly those they may need to take in the future. Individuals should also compare premiums, co-payments and other out of pocket costs.

  • On the Medicare website, you can search by plans available in your area. Click here to search for plans available to your ZIP code.