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Coverage options under Medicare

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Coverage options under Medicare

Coverage options under Medicare

There are a number of plans you can choose from. There are HMO plans; Medicare special needs plans, Medicare advantage plans, PPOs, PACE and cost plans. Each of the plans offers a separate set of benefits. You should go through the benefits offered by all the plans so that you can find one that is most suitable for you. This page will give you all the details you need.

Medicare offers a wide variety of options for you apart from Medicare Supplemental insurance. The Original Medicare plan is a type of Fee for Service plan covering a wide variety of services. It also covers specific prescription drugs. The member is allowed to choose any hospital or doctor who receives payments from Medicare.

If you are currently covered by a trade union, an employer or Department of Veterans Affairs, a special programme, TRICARE or Medicare Supplemental insurance, do not change them. Talk to the benefits administrator, a plan provider who is licensed or an insurer before you opt for changes.

Consider the costs of the plan, benefits you get, choice of hospitals and doctors, availability of facilities (proximity, hours, how they accept new members and services they will provide if you are out of station or out of the country). Also find out about the kinds of prescriptions you might need and whether they are needed for formularies. Ponder on the available pharmacies- their proximity to your home and whether you can call and avail of their services. Give all this serious thought so that you can know whether this coverage is more suitable for you compared to your present plans.

If you want any help in making a decision, go to Medicare Website. You can also dial 1800 633 4227 if you want to speak to a representative. You will get the information via mail within 3 weeks. You may also contact the State Health Insurance Assistance Program for details.

Alternatives for Medicare Supplemental Insurance

Apart from policies offered by Medicare Supplemental, there are options that can replace or supplement the Original Medicare plan you have. These plans are-

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

If you are enrolled for Medicare Part A and Part B and these plans are available in your area, you can get covered benefits under Medicare. You can also get prescription drugs coverage under Medicare Advantage plans or separate Medicare health plans. You can have a Medicare Cost or PFFS Plan as well as coverage under Medicare Prescription Drug Plan. You can get extra benefits on hearing, health, dental and vision plans. To obtain treatment, you may need to consult doctors belonging enrolled in the plan. The monthly costs required to run the plans determine your premiums. You may also have to pay certain out of pocket costs. However, co payments are lesser than the Original Medicare plan.

Medicare Advantage Plans.

The four plans listed first are under the category of Medicare Advantage Plans. These are options in health insurance controlled by the federal government and managed by private carriers. However, before the companies market these plans, they must seek approval from Medicare. Once you enroll in a Medicare Advantage plan, your health care requirements covered under Medicare are provided though this plan. HMO plans, Indemnity Plans, PPO plans, and Special Needs Plans are offered through the Advantage Plans. If you want to enroll for a Medicare Advantage Plan, make sure you are covered under Medicare Part A and Part B. You will also need to continue your premiums for Part B.

You may have to avail of the services of doctors within the network of Medicare as these plans are covered by private carriers. The kind of plan determines the provisions under this clause. The Medicare Advantage HMO plans provide for primary care physicians who provide you referrals to specialists if you need them. Medicare Advantage plans give you better coverage compared to Medicare Original, in spite of being administered by Medicare. This includes lower copayments charged for office visits, lesser hospital deductibles and coverage for prescription drugs. Usually you will find all the advantages of A, B and D plans under the same Medicare Advantage plan. As they are an amalgamation of all the Medicare plans, the Medicare Advantage plan is sometimes called Medicare Part C.

The Medicare Advantage fund provides a fee to the carrier offering you services. The said private company takes up the responsibility of managing your costs of healthcare and pays claims for your payments. While this may appear to be risky for the company concerned, Medicare pays them on a monthly basis even if no claims are made in the mentioned period.

Medicare HMO (Health Maintenance Organization) Plans

Under the HMO plans, you will find a selected group of providers and doctors. You must avail of services only from those who are part of the plan. Once you join this plan, you are given a list of providers who are included in the plans. If you are thinking about joining a HMO plan, it is better to find out whether your doctor provides service under these plans.

When you join a HMO plan, you will be required to select a primary care physician. You will get to see this doctor the most. You can go to a specialist if he recommends it. If you decide to change you primary care doctor, ask for a list of providers from the HMO. Doctors and providers are able to leave the plan at any time. If this happens, your plan will inform you beforehand so that you can go for a new one.

Another thing to note is that if you avail of services outside the network coverage, you will have to make all the payments. In certain cases, both the Original Medicare and the HMO plans will refuse to cover services outside the network. As such, you will pay for all the expenses. Medicare HMO plans are generally effective within a certain area. They accept enrolments and provide services within this area. However you may receive emergency and urgent care if you are outside the service area.

Before you go to a specialist, you will need a referral. This is basically a written permission provided by your primary physician stating that you may go to a specialist. Women may go for a mammogram every year without a referral. They can also go for women’s care services without referrals if you are allowed by state and federal regulations. Special rules are applicable if you are a lady and require services related to women. If your plan area does not have these facilities, the plan will manage them for you out of the network.

A Point Of Service is also offered by certain HMO plans. This allows you to go to hospitals and doctors outside the network. However, you may have to pay a hefty premium for this facility.

Medicare PPO (Preferred Provider Organization) Plans

These plans have many features of the HMO plans mentioned above. The difference is that in this sort of plan, you may use any doctor you want who will accept Medicare. Referrals are not needed if you want to go to a specialist or provider out of the network. You may have to pay more of out of pocket costs if you want to avail of services outside the network. You may get in touch with the plan to find out how much more you need to pay or whether the services are covered. You may get the services at a cheaper rate than the Original Medicare plan. Usually, PPO plans make payments for all covered services, even the ones that are out of the network. But all the plans are different and you may get differentiations for out of pocket costs.

As of 2006, PPO plans are available in major parts of the country to give you coverage under Medicare health insurance. Most PPO plans cover a single area but some may cover a single state or other areas. You may also get prescription drug coverage from Medicare health insurance. If your plan is a PPO that operates regionally, you get an added Medicare Part A and Part B Coverage. The out of pocket costs are limited and depends on the provisions of the plan.

Medicare Special Needs Plan

The special needs plans were started by Medicare in 2005. They usually restrict membership to particular people. It includes people, who are in long term care such as in nursing homes, people who are eligible for Medicare and Medicaid programs. People who have chronic and disabling diseases belonging to a particular list are also included. These plans may not be found in all areas. They are designed to provide healthcare services under Medicare to people who qualify. For instance, people with diabetes may be given providers dealing in diabetes who can offer counseling, medical nutrition and help to the members. They can also provide preventive counseling to the members.

Medicare PFFS (Private Fee for Service) Plans.

Medicare PFFS plans are a kind of Medicare plan offered by Medicare and run by private carriers. In this plan, you can use any facility or doctor who is approved by Medicare and is in line with provisions of your plan. Additional benefits like extra days in hospital may also be provided. Of course the company will decide how much is to be paid and the kind of service you will require. Medicare has no role to play in this decision. Prescription drug coverage will be made available to you if your plan provides for it. If it is not included in your covers, you can join the Medicare drug plan as an option.

Medicare Cost Plans

These plans are not provided throughout the country and the rules for it are more or less similar to Medicare HMO plans. You will receive covers under the Original Medicare plan if you are using providers outside the network. You will also need to pay the deductibles and coinsurance applicable to the services under Medicare Part A and B.

Medicare cost plans have enrollments in periods. So, whenever it is accepting new members, you will have to join. You may leave the plan as and when you desire and join the Original Medicare program. If the cost plan offers you prescription drug coverage, you can avail of it. If not, you can buy separate prescription drug coverage.

PACE (Program of All Inclusive Care for the Elderly).

PACE plans are available in some states under Medicaid options. PACE is a benefit permitted by the balanced budget act of 1997. It features a wide service delivery organization together with Medicaid and Medicare financing. The PACE program is designed to address the needs of long term patients and providers. It enables them to avail of services at home rather than settling them in institutions. Medical services needed by the patients are provided to him or her at home and are not limited to provisions under Medicare and fee for service programs.

Medicaid beneficiaries are often provided PACE services as a state option under the PACE model. Participants need to be at least 55 years of age, live in a service area under PACE and be certified to get home care by an agency of the state. For people who enroll in this program and are eligible for it, the PACE program becomes the only means of securing services for Medicare and Medicaid.

Medical facilities and doctors authorized by PACE get capitation fees under Medicare and Medicaid on a monthly basis on every person who enrolls. People who are eligible for Medicare but not for Medicaid pay premiums on a monthly basis that is equal to the capitation amount for Medicaid. They do not have to pay any coinsurance or deductibles.


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