Medicare Advantage & RX 

Medicare Advantage:

A form of private health insurance that provides the same coverage as Medicare Part A and Medicare Part B, and may include additional benefits such as dental, vision, and prescription drug. They bundle all the parts of Medicare Part A, Medicare Part B, a Supplement & Prescription Drug plan into one plan that is providing your health care through an Insurance Company of choice.

These plans include the same standard benefits as original Medicare; you must be enrolled in Medicare Part A and Medicare Part B to join. Keep in mind that you are by-passing Medicare to join this plan. The fact of the matter is, you’ve paid into the Medicare system your entire working life, & now you are giving up your rights & options for Medicare by enrolling into a plan that takes the place of Medicare (they DO include all the same benefits as Medicare Part A and Medicare Part B however). 

These plans have little to no monthly premiums, however outpatient medical coverage, inpatient hospital benefits, & Part D drug benefits ALL included. Again, many of these plans include dental vision & hearing coverage, along with a gym membership, & some other value-added benefits depending on which company to go with (AGAIN, WHERE WE AT ENROLLMENT BENEFITS HUB, CAN HELP).

Some plans restrict your coverage to “in-network” health care providers. Some plans require referrals. Many plans are County based and if you require care out of the County for non-emergency, you are considered “out of network”. 

COSTS OF PART C:

• You pay the original Medicare Part B Premium as discussed in the Medicare Supplement section (remember the average cost for 2022 is $170.10)
• You pay the Medicare Advantage premiums, which many are no cost. Yes, that’s right $0.00 ZERO DOLLARS!!!!
• There are Out of Pocket costs such as co-payments, co-insurance, and deductibles that you pay along the way. You pay these costs up to the plans out of pocket maximum, no more than $11,300 (for any company), per calendar year. This is considered a CAP or Maximum Out of Pocket (MOOP) and does not include Part D spending. 

TYPES OF MEDICARE ADVANTAGE PLANS:

There are different types of Medicare Advantage Plans:

HMO’S: Health Maintenance Organizations: These plans feature a network of participating health care providers. You typically select a Primary Care Doctor/Provider (PCP) who coordinates your care and makes referrals to specialist within your plan network.

PPO’S: Preferred Provider Organization: Unlike an HMO, a PPO may allow you to receive covered services from providers outside of the plan network, though you may pay higher out of pocket costs. PPO’s typically do not require you to have a PCP and you typically aren’t required to get a referral to see a specialist. 

SNP’S: Special Needs Plans: Certain type of Part C (Advantage Plans) that are designed for people with specific health conditions, or those who are dual eligible for Medicare/Medicaid. 

WHO IS ELIGIBLE? 

• You must be enrolled in Original Medicare Part A & Part B.
•  The plan must be offered in the area in which you reside.
• You do not have ESRD (End Stage Renal Disease).
• Under the age of 65, with a permanent disability and on Social Security Disability, or suffering from ESRD and undergoing dialysis or kidney replacement and other qualifying medical conditions. 

Let’s summarize the Medicare Advantage Plan:

Basically, you bundle Medicare Part A & Medicare Part B, a Medicare Supplement & Prescription Drug Plan all into one plan with one card, & often just the Part B premium. You are confined to the parameters of the Insurance Company & you follow their rules. You will experience co-pays along the way depending on what sort of health ailments you go through.

How on earth do you begin to even compare plans?

YOU DON’T, YOU LET US AT ENROLLMENT BENEFITS HUB, do that for you!

Just in case you want to double check our recommendations, you can pay attention to:

• Type of plan
• Benefits Comparison
• Star Rating
• Costs such as co-pays, deductibles, and Maximum Out of Pocket (MOOP) 

RX (Part D):

A stand-alone Medicare Part D Prescription Drug Plan helps pay for prescription drug medications. It is purchased separately from your Medigap plan.

• Price ranges between $7.50-$101.10 (Depending on the state)
• One plan is NOT better than another, it’s ALL based on your specific individual prescriptions.
• These plans MUST be reviewed annually. Formulary & plan changes are made every year plus, you get to talk with us again.
• You MUST have a Part D plan or another credible drug coverage (for example: The VA, Tri-Care, Group Health Insurance through an Employer)

Medicare Part D plans cover certain prescription drugs. The Federal Government sets guidelines for the types of drugs that Part D plans must cover. Each Part D plan decides which specific drugs it will cover as well as the cost of the plan that members will pay. When comparing Part D coverages (WHICH IS OUR RESPONSIBILITY, AT ENROLLMENT BENEFITS HUB) be sure to check your plans formulary, (drug list) to make sure all of your prescriptions are included.

PART D COVERAGE RULES:

Medicare Part D prescription drug coverage plans may impose certain rules to help ensure that prescription drugs are used appropriately and cost effectively. 

The more common types of these coverage rules are: 

• Prior Authorization
• Step Therapy
• Quantity Limits
• Excludable Drugs 

Medicare Part D plans provide for exclusions, specifically, plans are NOT required to cover any of the following: 

• Non-Prescription (over the counter) drugs
•  Drugs covered by Medicare Part A & Part B 
• Prescription vitamins and minerals except for fluoride and prenatal vitamins
• Drugs used to treat anorexia, weight loss, or weight gain o Drugs used to treat erectile dysfunction
• Fertility drugs
• Hair growth and other cosmetic drugs