Medicare Advantage Plans are not part of Original Medicare.
Medicare Advantage Plans were added as Part C of Medicare as part of the Balanced Budget Act of 1997. Part C was known as Medicare + Choice, which meant a person could choose to enroll in a Medicare Advantage Plan and have that private insurance company manage their healthcare instead of Original Medicare. Part C is highly regulated and must contain all the benefits of Medicare Part A and Medicare Part B.
Medicare Advantage Plans could add more benefits to their plan, but they are not allowed to provide less benefits than Original Medicare provides under Part A and Part B.
Medicare Advantage Plans have networks of physicians and facilities in their plans. The member must utilize a physician or facility in their network in order for the insurance plan to pay the medically necessary bill.
Medicare Advantage Plans usually require referrals to see a specialist or to have a procedure done. The private insurance company contracted with Medicare, determines what physicians and facilities are in their network and what procedures are approved or denied.
A person enrolled in a Medicare Advantage Plan usually has to pay a co-pay when they see a physician or have a diagnostic procedure. Medicare Advantage Plans have different co-pays from plan to plan. It’s important to do your own due diligence to find out what your out of pocket expenses will be on a Medicare Advantage Plan.
If you see a physician out of network you will most likely pay higher co-pays.
Emergency situations are an exception. If you have a true emergency and require medical treatment at an out of network facility, a Medicare Advantage plan will likely pay the medicare allowable bill minus your scheduled co-pay for that type of facility. You will most likely be asked to provide the medical documents from the out of network facility, in order to prove you had a true emergency and couldn’t wait to see a physician or facility in your plan’s network.
Physicians and facilities currently have the option of terminating their contract with the Medicare Plan provider – when they want. Contracts are not always signed from January 1st through December 31st of a calendar year. Contracts with physicians and facilities are signed in different months. Each physician and/or facility may terminate the contract and leave the network.
If you were seeing Dr. Jones as your primary doctor under the XYZ Medicare Advantage Plan and Dr. Jones decided to terminate his contract with XYZ Plan – he can. Where does that leave you? Stranded. You will not be able to see Dr. Jones under XYZ plan anymore and you are locked in under CMS regulations. You cannot change your Medicare Plan until October 15th and the new plan won’t go into effect until January 1st of the next year. You will be forced to find a new primary doctor.
On Medicare Advantage plans, you will most likely need referrals to see specialists. Your primary doctor will need to refer you to a specialist and the Medicare Advantage Plan will have to approve the referral.
If your cardiologist states you need a catherization test to determine if you need a stent, the Medicare Advantage Plan must approve the test prior to you taking it.
You must be flexible to be comfortable under a Medicare Advantage Plan. If you don’t mind changing doctors, having referrals to see doctors and having to get all your tests and procedures authorized, a Medicare Advantage Plan may be for you.
(855) 855-SAMM (7266)
Senior Advocates For Medicare & Medicaid