Medicare Advantage Plans are health plan options that are part of the Medicare program. These Medicare plans are offered by private insurers and pay for the same health care services as Original Medicare (except hospice care and some care in qualifying clinical research studies that Original Medicare still covers even if you are in an Advantage Plan). Medicare beneficiaries electing this option must be accepted into the plan regardless of any health condition, except kidney dialysis. Those residing outside of the plan service area are also not eligible or, beneficiaries may be excluded if the plan has reached a capacity limit.
Beneficiaries condsidering an Advantage Plan should understand the yearly costs associated with that election since they are different than those of Original Medicare. Advantage Plan enrollees continue to pay monthly Medicare Part B premiums to the Federal Government and can be charged additional monthly premiums to belong to the plan. There are insurance co-payments for most medical services such as provider office visits, lab work, therapy, hospital stays and durable medical equipment. Every plan has its own maximum out of pocket (the most you can pay in copays for the plan year) with most, if not all service co-payments included (cumulatively) in that maximum. Paying a higher monthly plan premium may result in a lower insurance co-payment schedule and/or a lower annual out of pocket maximum.
Advantage Plans may offer additional coverage, like vision, hearing, dental and wellness programs. And most include prescription drug (Part D) coverage. Beneficiaries may want to contact the plan for the most accurate information on plan costs and the benefit structure.
Another important element in choosing an Advantage plan is learning if the plan has a defined network of providers and if their doctors are part of that network. Beneficiaries are encouraged to contact their medical providers prior to enrolling to be sure they are part of the network and accept the plan.
There are specific periods of time during which a beneficiary may join, switch or drop an Advantage Plan. These are called the "Enrollment Periods" or "Special Enrollment Periods".
Before a decision is made whether to join, switch or drop an Advantage Plan, be sure to understand all options and timelines so the "one time" election for change is not used up in each enrollment period. Call the Wisconsin Medigap Helpline at 1-800-242-1060 with any questions regarding coverage in an Advantage Plan.
Initial Coverage Election Period (ICEP) - When first eligible for Medicare, a decision needs to be made by the beneficiary to remain in Original Medicare or to join an Advantage Plan. The ICEP runs from 3 months before starting Medicare, includes the month Medicare begins, and continues for 3 months after Medigare begins (7 month time span).
Annual Election Period (AEP) - October 15 through December 7 of each year is the AEP referred to by most as the "Medicare Open Enrollment Period" with plan choices becoming effective January 1st of the following year. During the AEP, individuals may join, switch or drop an Advantage Plan. Note: The last election made during the AEP will be the plan that becomes effective in January. During the AEP an election into a Medicare Prescription Drug plan (Medicare Part D) may also be made.
Annual Disenrollment Period (ADP) - January 1 through February 15 of each year is the ADP. Note: during the ADP, individuals may only drop their Advantage Pan and return to Origianal Medicare. They then have a Special Enrollment Period (SEP) to join a Medicare Prescription Drug Plan (PDP). The changes will become effective March 1 of that year. A beneficiary may want to cover Medicare out of pocket costs by purchasing a Medigap Insurance (supplement) Plan, however, they can be denied coverage due to medical underwriting.
Special Election Period (SEP) - There are circumstances that provide a beneficiary the right to add, switch or drop their Advantage Plan on a one time, limited or ongoing basis ourstide of the ICEP, AEP called Special Election Periods (SEP). If relocating from a plan service area or losing current coverage through no fault of their own a beneficiary will be allowed a one-time SEP to a new Advantage Plan or to return to Original Medicare. If the beneficiary becomes institutionalized or becomes eligible for Medicaid or a Medicare Buy-In Program (QMB, SLMB, QI-1) they will have (ongoing SEP) continuous enrollment opportunities to add, switch or drop a Medicare Advantage Plan.
Federal Trial Periods (SEPs) - These are one-time SEPs. If a beneficiary chooses to enroll in an Advantage Plan when first starting Medicare at age 65 (SEP 65) or if switching from Original Medicare and a Medicare Supplement, at any age, (Supplement SEP) to join an Advantage plan for the first time they will have an SEP to drop the Advantage Plan, outside of the AEP or ADP, and return to Original Medicare. Together these SEPs may only be used one time during their first 12 months of enrolling into the first Advantage Plan. They will then return to Original Medicare and will have a Guaranteed Issue right of 63 days to purchase a Medicare Supplemental Policy.
(Note: The State of Wisconsin recognizes a "special state trial period" for those who left an employer sponsored coverage to enroll into an Advantage Plan; they also have a 12-month trial period. However, they may only drop the Advantage Plan during recognized election periods (ie AEP, ADP or SEP). They will then have a Guarantee Issue Right to purchase a Medicare Supplemental policy.)
5 Star (SEP) A beneficiary may join an Advantage Plan or Prescription Drug Plan with a performance rating of (5) stars at any time of the year (December 8 - Novermber 30). This SEP may be used only once each year. The beneficiary must meet other basic requirements to join an Advantage Plan with coverage effective the 1st of the month following the month in which 5 star plans receive an enrollment request. Caution: Not all 5 star plans include prescription drug coverage and the beneficiary may not be able to keep current drug coverage, so before enrollment, understand what would happen with current drug coverage (call the Medigap Part D and Prescription Drug Helpline @ 1-855-677-2783 for details).
Types of Medicare Advantage Plans:
Beneficiaries have several types of Advantage plans to choose from. All Advantage Plans must follow Medicare rules and cover all Medicare services. How the plans pay benefits for those services depends on the plan.
Private Fee for Service Plans - (PFFS) - In a PFFS plan, you can generally go to any doctor, other health care provider, or hospital as long as they agree to treat you but these plans must also have a defined network of providers that accept the plan. If the PFFS plan does not include prescription drug coverage you may add a stand alone Prescription Drug Plan (PDP).
Preferred Provider Organizations - (PPO) - In a PPO plan,you pay less if you use doctors, hospitals and other health care provider that are in the plan's network. You usually pay more if you use providers outside the network. Generally these plans include prescription drug coverage so a separate Medicare Part D plan (PDP) is not allowed.
Health Maintenance Organization - (HMO) - In an HMO plan, you can only go to doctors, hospitals or other health care providers in the plan's network except in an emergency. These are managed care plans with a strictly defined network that must be used in order to have benefits. If an out of network provider is chosen without a referral, the benficiary will be responsible for the full costs of care. Emergency services are covered in or out of network. Generally these plans include prescription drug coverage so a separate Medicare Part D plan (PDP) is not allowed.
Health Maintenance Point of Service (HMO-POS) - In an HMO-POS plan, benefits are allowed even if you get non-emergency care at an out of network provider without a referral. This is not always included with an HMO plan. (Check with the plan for details on the POS coverage area). Generally, these plans include prescription drug coverage so a separate Medicare Part D plan (PDP) is not allowed.
Special Needs Plan (SNP) - In an SNP plan, the plan provides focused and specialized health care for specific groups of beneficiaries, like those who have both Medicare and Medicaid (dual-eligible), live in a nursing home, or have certain chronic or disabling medical conditions. Check with the plan to get further information. Generally these plans include prescription drug coverage so a separate Medicare Part D plan (PDP) is not allowed.
Medicare Medical Savings Accounts:
A Medicare Medical Savings Account plan is a high-deductible Medicare Advantage Plan combined with a savings account. Each year funds are deposited into the savings account by Medicare. The funds from that Account receive tax breaks when used for approved medical services. Consumers themselves may not contribute to the savings account. Funds may be used for all qualified expenses, not just medical. Once the plan's deductible is met, Medicare medical services are then coveed at 100% by the plan for the balance of the calendar year. Any funds remaining at the end of the year in the medical savings account are rolled over to the next year and will continue to accrue if they remain unused.
These plans do not offer drug coverage so a separate Medicare Prescription Drug Plan (PDP) is necessary. Special rules apply to entry and exit from these plans. For more information about these plans go to "Your Guide to Medicare Medical Savings Account Plans". For additional information about tax implications go to "Health Savings Accounts and other Tax Favored Plans". For information on what expenses are qualified for this type of plan go to "Medical and Dental Expenses". These plans are also known as Archer MSA's.
For more information:
To view a list of all the Medicare Advantage Plans in available in a specific Wisconsin zip code, go to http://www.medicare.gov/ and select "Compare Health Plans" in the search tools. A zip code will be entered to identify available plans. Comparison of the plan's co-pay structures and costs may be viewed.
A non-ZIP code specific list of WI Medicare Advantage Plans is available in the "Medicare and You" publication that is mailed to every Wisconsin Medicare Beneficiary each fall.
For further information about Medicare Advantage Plans in Wisconsin, go to this site: http://oci.wi.gov/pub_list/pi-099.htm
Last Modified: 7/28/2016 9:52:28 AM