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Various Medicare Cover Options

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 Various Medicare Cover Options
Various Medicare Cover Options

Various Medicare Cover Options

Medicare offers various options for the people wanting to enroll into an insurance plan, in addition to Medicare Supplemental Insurance. Under the fee-for-service Original Medicare plan, numerous health care services and prescription drug plans are listed and you are usually provided with the option to pick any physician or hospital, who accepts Medicare payment. Refrain from making any changes in your present coverage in following cases: you are either covered by a trade union, your employer, TRICARE, Department of Veterans Affairs, a special program or a Medicare supplemental policy. If you need to make changes than firstly discuss it with either the insurer, a benefits administrator, or a licensed plan provider.

Things to Consider Before Choosing Any Medicare Plan Are:

  • Before signing up for any Medicare plan, take time to consider its cost and benefits, choice of physician and hospital, how close to your residing area these services are, their work timings, whether they accept new patients.
  • How these service providers will help you in case you need immediate medical attention outside of the state or the country.
  • Would you require any other type of prescription in additional to what you have? Then know your options and find out what's included in your plan's formulary.
  • Find out what pharmacies are covered under your plan and how close they are to your house. Could you order by just calling them?
  • Lastly, analyze if you new plan will meet the expectations you have grown due to your previous or present health coverage.

Medicare Supplemental Insurance Substitutes

In Medicare, there are various other plans available with which you can either replace or supplement your Original Medicare plan, apart from Medicare supplemental policies. These alternative options are mentioned below:

  • Medicare HMO (Health Maintenance Organization) Plans
  • Medicare PPO (Preferred Provider Organization) Plans
  • Medicare Special Need Plans
  • Medicare PFFS (Private Fee for Service) Plans
  • Medicare Cost Plans
  • Demonstrations
  • PACE (Programs of All-inclusive Care for the Elderly)

If you are enrolled in Medicare Part A and Part B plan and any of the abovementioned plans are offered in your area, then these plans can provide you with Medicare benefits. In case, you have Medicare HMO, then you might stay in Part B only. You will have to pay monthly premium prescription drug plan and extra insurance benefits.

Remember, you have same rights and protection as in Medicare program, even if you sign up for any of the aforementioned plans and will be entitled to receive benefits from all the regular Medicare covered services. You can avail prescription drug plan benefits, if you are in any Medicare health plans or Medicare Advantage plans. Even if you are enrolled in Medicare Cost Plan or PFFS, you are still eligible to join Medicare Prescription Drug Plan. Find out if you are eligible for extra benefits as well such as hearing, dental, vision and other health care benefits. Usually, you are required to see physician that's enlisted with your plan when you need treatment. You could have pout-of-pocket expenses and your plans monthly premium's depends largely on plans monthly costs. These expenses usually run lower than the original Medicare plan, if you have to pay co-payments for services.

About Medicare Advantage Plans

The initial four plans mentioned below fall under Medicare Advantage Plans. Understand that Medicare Advantage Plans are managed by private health insurance providers, but it governed by federal government. Hence, any private insurance provided interested in offering these plans must be sanctioned by Medicare. All your Medicare approved health care needs are offered via whatever Medicare Advantage plan you join. Some Advantage plans are HMO, PPO plans, plans for people with special needs and fee-for-service (Indemnity) plans. To become qualified to be signed up for Medicare Advantage plan, you must be already part of Medicare Part A and Part B plans. Also, you are required to keep paying premium for your Part B plan.

You might be allowed to use only physicians covered under Medicare network of your insurance provider, considering Medicare Advantage Plans are offered via private insurance companies. Rules of use also depend largely on kind of plans you have purchased. In Advantage HMO plans, you choose primary doctor, who looks after your health care needs and refers you to specialist within covered medical group if you need it. You get much better coverage with Medicare Advantage Plans as compared to the original Medicare. These advantages include lower deductibles on hospitalization, on prescription drugs and co-payments for office-visits. Mostly, Medicare Advantage plans provide you with all the benefits covered under Part A, B and D plans. since Medicare Advantage plan is combination of three Medicare plans, it's also referred to as Part C plan.

The private health insurance companies receive a monthly fee from Medicare, for managing Medicare Advantage plans. In return, private insurance company assumes risk of maintaining your health care and pays claims related to your medical treatments. Sounds like a risky undertaking from insurance company's view point, but they are paid well for assuming this risk by Medicare for all Medicare Advantage members, even if members don't have any claim during certain month.

Medicare Health Maintenance Organization (HMO) Plans

This plan enlists network of doctors and hospitals, and clients are required to use services from doctor or hospital listed with HMO plan. At the time of enrollment into the plan your Medicare HMO provider will inform you about doctors and hospitals that accepts patient from this plan. Check with your physician if he/she is working with Medicare HMO plan, before signing up for it.

You will be asked to choose your primary care physician when you first join HMO plan. This doctor will be looking over your primary health care and will suggest a specialist if you need it. If you are looking to change your primary physician, then HMO plan provider for the names of doctors around your residence area. Doctors leave and join these plans whenever they wish, in such scenario, your pan lets you know about the development in advance, which gives you choice to choose new doctor.

If you get health care services outside of plan's network, then you are usually entitled to pay for them. In many cases, you are solely responsible for all of the medical expenses, without any help from either the Original Medicare Plan or the HMO plan.

Medicare HMO plans are generally offered in some areas in the country and there's a set geographic boundary defining, what services are provided in which areas and where members are accepted. Your plan might cover your medical expenses, if you needed emergency treatment and are not anywhere near your plan's service area.

As per terms of this plan, you require referral from your primary physician if you need to see a specialist. A referral is a written permission from your physician to see specialist for care. However, women can see a specialist without referral for a mammogram and each year for other care services charted by state and federal health insurance regulations.

As per some special terms if a woman in the plan needs women's care services and those services are not available in the plan, then plan will arrange for care outside their network. Some Medicare HMO Plans also offers a plan named, Point of Service that allows you to see physician and hospitals not a part of the network. But if you opt for this then it can increase your monthly premium.

Medicare Preferred Provider Organization (PPO) Plans

Some of the rules under PPO plans are same as it in Medicare HMO plans. Under PPO plans, you are free to visit any physician, who accepts Medicare coverage and clients. Another advantage is you are not required to take written referral from your primary physician to see specialist, who may or may not be enrolled in your plan providers' network. But, remember, if your visit out-of-network physician or hospital, then this might increase your out-of-pocket expenses on health care. Check with your plan or insurance provider to find out what services, you need, are covered and how much you will have to pay if they are not. Generally, these plans provide you with more benefits than the Original Medicare Plans and that too on lower cost. Your out-of-pocket expenses differ with each plan but PPO plans pay for all the covered services even if they are out of network.

Since 2006, Medicare PPO Plans started to offer more choices for Medicare health insurance coverage in most parts of the country. A regional PPO Plans serve an entire region, but they can be expanded into many state areas or single one. These plans allow people enrolled into this plan to sign up for Medicare prescription drug plan. Your out-of-pocket expenses are also limited under this plan and largely depend on the type of plan you have purchased. The regional PPO plans are also offer added protection for Medicare Part A and B plans.

Medicare Special Needs Plans

From 2005, Medicare has been providing people with a new plan, referred to as "Special Needs" plans. Under these plans, all or certain part of membership is restricted to certain persons. This include people in long term care facilities like nursing home, individuals with certain disabling illnesses, or for people eligible for Medicare and Medicaid plans. These are specifically designed plans and are only made available to people who qualifies for it. Also, they are not available in most areas. Take example of diabetics, who might have additional insurance providers, who specializes in providing services for diabetes and also offers counseling, exercise or nutritional programs, designed to control the ailment to certain extent.

Medicare Private Fee-For-Service Plans (PFFS)

PFFS plans are also among Medicare plans that are offered to people via private insurance companies. Under these plans, you are free to use physician and services approved by Medicare. You could be granted extra benefits like extra days in hospital, if you need them. In these plans, private companies decide what services you might require and how much amount it will pay. Medicare is not a factor in their decision. You get prescription drug coverage if its offered to you, but you are free to join optional Medicare prescription drug plans if it was not offered to you at the time of joining by your Medicare PFFS plan.

Medicare Cost Plans

Medicare cost plans are not available all across the country and rules dictating this plan are similar to Medicare's HMO plans. Even if you end up using non-network provider, you are still qualified for the medical services offered by your Original Medicare Plan. For availing the services, you will have to pay Part A and B co-insurance and deductibles.

Since these plans are open for new member periodically, make sure to enroll into one whenever they are accepting new memberships. Also, know that you can choose to return to your Original Medicare Plan, leaving Medicare Cost pan whenever you deem right. You prescription drug cover from your Cost Plan, only when you are offered the plan and you can simply buy a separate prescription drug plan, if it's not offered to you.

Program of All-inclusive Care for the Elderly (PACE)

Program of all inclusive care for the elderly are offered in some states of the United States as an option under Medicaid plan. The PACE is capitated benefit sanctioned by the Balance Budget Act of 1997, featuring comprehensive service delivery system with integrated financing for Medicare and Medicaid. PACE was designed to meet the needs of long-term care clients, payer and providers. It permits people to continue living at their place. This plan ensures that clients keep living at their place and also gets proper medical care without having to be institutionalized. Capitated financing makes sure that medical providers offer all medical services needed by the clients at the time of treatment. It not limited like Medicare and Medicaid fee-for-service system.

The PACE model has been designed in such a manner that certain states can offer it to Medicaid beneficiaries as a state provided option. To enroll into this plan, your age must be 55, you should be resident of PACE service sear and should be certified as eligible to get nursing home care by appropriate State agency. The PACE is the sole source of services for those you are eligible and join this program.

Physician and medical facilities that are sanctioned by PACE receive Medicare and Medicaid capitation payment each month got each eligible enrollee in the plan. People who are part of Medicare, but are not eligible for Medicaid, will have to pay monthly premiums that are equal to Medicaid capitation sum. But they are not to pay co-insurance or deductibles.

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Various Medicare Cover Options

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