enrollment and a stand-alone Part D drug plan. Some beneficiaries may have secondary coverage, such as Medicaid, which will impact their decision.<\/span><\/p>\nA few factors that you can consider are:<\/span><\/p>\n\n- Am I healthy?<\/span><\/li>\n
- How often do I go to a healthcare provider?<\/span><\/li>\n
- How many prescription drugs do I take?<\/span><\/li>\n
- Are your prescriptions brand names or generics?<\/span><\/li>\n
- Do you travel?<\/span><\/li>\n
- Are you okay with staying in-network and needing referrals for a specialist?<\/span><\/li>\n<\/ul>\n
If you\u2019re not in a situation where you can enroll in a Medicare Supplement plan for healthcare and a Part D plan for prescriptions, then a Medicare Advantage plan could be a good option for complete Medicare insurance.<\/span><\/p>\nThe prescription drug coverage under both Part C and Part D is divided into four phases outlined by the Centers for Medicare & Medicaid Services:\u00a0<\/span><\/p>\n\n- Deductible phase: <\/b>You pay the total amount of the prescription until the deductible is met.<\/span><\/li>\n
- Initial coverage phase: <\/b>Your plan will help you pay for covered prescription drugs. The plan pays some cost, and you pay a copay or coinsurance.<\/span><\/li>\n
- Catastrophic coverage phase: <\/b>After you\u2019ve spent a certain amount on covered drugs, you pay no further cost-sharing.<\/span><\/li>\n<\/ul>\n
In addition to the coverage phases, your drug costs are determined by the drug tier or category assigned.<\/span><\/p>\n\n- Tier 1\u2014Preferred generics<\/b>: These drugs typically have the lowest copays.<\/span><\/li>\n
- Tier 2\u2014Non-preferred generics:<\/b> These prescriptions are the second lowest cost.<\/span><\/li>\n
- Tier 3\u2014Preferred brand: <\/b>Tier 3 drugs are common brand-name drugs.<\/span><\/li>\n
- Tier 4\u2014Non-preferred brand:<\/b> Tier 4 prescriptions typically are high-cost brand-name drugs.<\/span><\/li>\n
- Tier 5\u2014Specialty tier:<\/b> Specialty drugs are typically set as a coinsurance amount. These are uncommon drugs that sometimes involve compounding.<\/span><\/li>\n<\/ul>\n
Part C coverage\u00a0<\/span><\/h3>\nAll Medicare Advantage plans, except for Private Fee-for-Service (PFFS) plans, require prescription drug coverage. The plans must cover Medicare benefits at least as well as Original Medicare and are required to limit out-of-pocket costs for the year.<\/span><\/p>\nIn addition to having comprehensive coverage combined into one low-cost plan, these plans also boast additional plan extras that Original Medicare doesn\u2019t cover. These plan extras may include:<\/span><\/p>\n\n- Dental coverage<\/span><\/li>\n
- Dentures<\/span><\/li>\n
- Eyeglasses<\/span><\/li>\n
- Routine Eye Exams<\/span><\/li>\n
- Gym Memberships<\/span><\/li>\n
- Health Food allowances<\/span><\/li>\n
- Over-the-counter allowances to buy items such as toothpaste and <\/span>aspirin<\/span><\/li>\n
- Utility bill assistance<\/span><\/li>\n<\/ul>\n
Not all plans will cover all of these benefits; thus, if a particular service is needed, it is important to consult a licensed insurance agent. They can go over the benefits and plan extras available to help you make an informed decision about which plan is best for your needs.<\/span><\/p>\nSince each plan is different, copays, deductibles, and formularies will differ from plan to plan. However, they all follow the Medicare standard drug plan model, and Medicare Advantage plans come in several options.<\/span><\/p>\n\n\n\n\nMedicare Advantage Plan Types<\/span><\/h2>\n<\/th>\n<\/tr>\n<\/thead>\n\n\n| Preferred Provider Organization<\/span> (<\/span>PPO)<\/span><\/td>\n | \n\n- PPO plans have options with and without drug coverage.<\/span><\/li>\n
- PPOs<\/span> will typically not require <\/span>referrals<\/span> and allow out of network services.\u00a0<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
\n| Health Maintenance Organization<\/span> (<\/span>HMO)<\/span><\/td>\n | \n\n- HMO<\/span> Plans have options with and without drug coverage.<\/span><\/li>\n
- HMOs<\/span> will require <\/span>referrals<\/span> and authorizations to see specialists and do not cover out-of-network providers.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
\n| Private-Fee-For-Service (PFFS)<\/span><\/td>\n | \n\n- PFFS plans come with or without drug coverage. If a PFFS doesn\u2019t include drug coverage, a stand-alone <\/span>Part D prescription drug plan<\/span> can be added.\u00a0<\/span><\/li>\n
- PFFS plans allow you to utilize any provider that accepts Medicare. They come in PFFS with networks or without. If using in-network providers, it will work similarly to a <\/span>PPO<\/span>.<\/span><\/li>\n
- When using non-network providers, they must agree to the terms and conditions of the PFFS before seeing a patient.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
\n| Special Needs Plans<\/span> (<\/span>SNP)<\/span><\/td>\n | \n\n- SNPs<\/span> are designed for people with particular <\/span>health care<\/span> needs and will always include drug coverage.\u00a0<\/span><\/li>\n
- There are three types of <\/span>SNP<\/span> plans:<\/span>\n
\n- Dual <\/span>SNPs<\/span> are designed to work with Medicare and <\/span>Medicaid<\/span>. You\u2019re required to maintain the correct level of <\/span>Medicaid<\/span> to be allowed to <\/span>enroll<\/span> in the plan.<\/span><\/li>\n
- Chronic <\/span>SNPs<\/span> are for people who have qualifying health conditions.<\/span><\/li>\n
- Institutional <\/span>SNPs<\/span> are formulated for people who are living in an institutionalized setting.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
The disadvantage to Medicare Advantage plans is that since private insurance companies run them, the plan administrator, not Medicare, approves and denies Medicare care referrals and procedures. In addition, many Medicare Advantage plans are network-based.<\/span><\/p>\nOne advantage of Medicare Part C is the out-of-pocket maximums which limit individual costs. Original Medicare does not have a cap on what you could spend on medical services throughout the year.<\/span><\/p>\nAnother benefit is that there isn\u2019t a need to enroll and pay for additional insurance coverage to ensure all your needs are covered. Medicare Advantage plans combine parts A, B, and D of Medicare into one (Part C) and may give you additional coverage for services not covered by Medicare.<\/span><\/p>\n | | | | |
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