• March 29, 2023

Insurance policy coverage Options for Medicare Entitled Persons

Individuals with Medicare can obtain their medical care through original Medicare or the Medicare Advantage Program (Part C). Medicare Advantage Plans consist of HMO, PPO, Private Fee for Service Plans and Special Needs Plans. Of the over 10 million individuals enrolled in Medicare Advantage Plans, the majority are enrolled in HMO’s (Health Maintenance Organizations) which have been available because the 1980’s.

To greatly help your parents (or you) make the best decision, they should know how these plans work, and then decide which plan is right for them. The next is just a brief description of all the plan types.

Original Medicare
If someone elects to go with traditional fee for service Medicare, they are able to generally use any doctor or hospital that accepts Medicare assignment anywhere within the United States. However, Medicare has deductibles, copays and cost sharing requirements that may play havoc with budgets. To greatly help pay these additional out of pocket expenses, many individuals purchase Medigap or Medicare supplement policies.

Medicare Advantage Plans (Part C)
In the event that you opt to go with a Medicare Advantage Plan, you really trade your traditional Medicare benefits for these plans. Lots of the Medicare Advantage Plans are given to eligible individuals at little or no cost besides continued payment of their Part B monthly premiums.

Medicare HMO’s (Health Maintenance Organizations)
These plans cover the same physician and hospital costs as traditional Medicare, but usually with lower out of pocket costs. HMO’s are attractive to Medicare eligible individuals because they often provide extra benefits like eyeglasses, hearing aids, and dental benefits which are not included in traditional Medicare.

Individuals considering a Medicare HMO should be aware that they’ll only receive medical services from providers who’re area of the HMO’s network of contracted providers. The HMO usually requires an individual joining their plan select a primary care physician from those that participate in their network. This primary care physician would then result in all medical care including referrals to a specialist and admittance to a hospital. The HMO will not buy unauthorized visits to specialists nor non-emergency care received beyond your HMO’s service area or visits to non-network physicians.

These plans are private healthcare plans like HMO’s. However, PPO’s and HMO’s do differ into two essential areas. First, Medicare PPO’s do cover eligible medical care services obtained from doctors and hospitals beyond your PPO network. And, second, Medicare PPO’s don’t usually require that you obtain an authorization before seeking care from the specialist.

Regional PPO’s are available in many regions of the country. These plans serve large geographic areas and must offer the same premium costs and plan benefits to all individuals residing in these areas. Medicare PPO’s cover the same types of medical expenses that traditional Medicare does. In addition, Medicare PPO’s commonly add a prescription drug benefit. Unlike traditional Medicare, Medicare PPO’s have an annual out of pocket limit for benefits covered under Parts A and B of Medicare. The out of pocket limit caps the total amount someone can devote to covered medical expenses in a calendar year. Much like any PPO program, when someone runs on the non-contracted provider for covered services, they’ll pay more out of their pocket.

These plans are available to Medicare beneficiaries in trade due to their traditional Medicare Benefits. PFFS don’t have an official network of doctors and hospitals to pick from and not all doctors or hospitals are willing to supply medical services to participants in these kinds of plans. If someone is considering enrollment, it’s wise to check using their doctor and local hospitals to make sure that they’ll accept the plan’s payment for services before enrolling. Also, the enrollee should thoroughly understand the advantages of a fee for service plan because the fee for service plans decide just how much they’ll buy  Myaarpmedicare Medicare covered services and may charge a greater cost sharing percentage than traditional Medicare. Private fee for service plans may add a prescription drug benefit. If they do not, the enrollee is free to become listed on a Medicare stand alone prescription drug plan.

These plans are private plans offering benefits to Medicare beneficiaries, including prescription drug coverage, who need additional help paying for their medical benefits. These would include individuals who qualify for both Medicare and Medicaid (MediCal in California), those residing in long haul care facilities, and people that have chronic or disabling medical conditions.

Prescription drug plans are available to all Medicare eligible persons no matter medical history or income levels. When a person first qualifies for Medicare, their initial enrollment period begins three months before their 65th birthday, includes their birth month, and ends three months after their birth month. Otherwise, the annual open enrollment period for prescription drug plans runs from November 15th thru December 31st, with the coverage commencing on the next January 1st.

Medicare drug plans are made to reduce drug costs for enrollees and protect against catastrophic drug costs. However, there’s a regular cost for these plans. In addition to a regular premium, the covered individual is required to pay a share of the expense of the medications (or a copay) and Medicare pays area of the cost. Costs for a plan can vary with regards to the medications taken and the kind of plan selected. At least, the plans available must supply a “standard” level of coverage.

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