Let’s start with the fact that most people don’t realize that Advantage Plans are the same things as ‘Part C’, which is what Medicare calls them. So if you see an advertisement on TV saying you may be eligible for Part C, and you should call so you don’t miss out, they are usually intentionally misleading you. The fact is, you probably already have Part C, but you know it as an ‘Advantage Plan’. The terms are interchangeable. However, there are many different types of Advantage Plans through many different carriers. Here is a bit of help on deciphering what is available and what you may or may NOT be eligible for……
Health Maintenance Organization
This is most known as an HMO. Most, if not all, insurance carriers offer an HMO-type Advantage Plan. Some carriers offer several HMO plans. What are the characteristics of an HMO? The primary limitation with HMOs is that they have no out of network coverage. So this type of Advantage Plan can be considered the most restrictive as far as network. This doesn’t necessarily mean they are bad. Because they are more restricted, they have the ability to offer more robust ancillary benefits like more dollars in dental, flex spending cards, Part B premium reductions, OTC benefits and even money for groceries. They typically have a lower Out Of Pocket Max as well. So, there is an upside as long as the other criteria fits for the individual. Be sure to seek guidance from a local independent agent so they can ensure your drug costs fit, and your doctors are in network!
Preferred Provider Organization
Also known as a PPO, this type of plan has more network flexibility. It has out of network coverage, and you won’t need a referral to see a specialist in most cases. However, there is incentive to stay in network in that your copays and coinsurance amounts are less if you see in network providers. With the added network flexibility and mobility comes slightly less robust ancillary benefits. The Max Out of Pocket may be higher than HMOs, and there just may be less bells and whistles. But for many, the knowledge that you can see anyone you need to see or receive care from anywhere is worth less perks. And the PPO plans still include the basic Dental, Vision, Hearing and Gym/Wellness benefits.
Special Needs Plans
There are several kinds of Special Needs Plans for certain individuals who qualify based on special circumstances. These can be either an HMO or PPO by design. Here is a breakdown:
DSNP – Dual Eligible Special Needs Plan. This plan is designed for people who have BOTH Medicare and Medicaid. The plans have some drastically enhanced perks and benefits. They also usually have $0 copay amounts for most of the medical services. There is still a difference in drug cost and formularies, so make sure you have a local agent vet the plans for you.
ISNP – Institutional Special Needs Plan. This plan is designed for those individuals who are Medicare eligible and reside in an institutional setting. Most include a Care Model set up to provide enhanced clinical services within the institution. You must use a ‘captive’ or employed agent to enroll, and the institution or nursing home must have a contract in place with the ISNP plan to offer it. The best person to ask is the facility Social Worker.
CSNP – Chronic Special Needs Plan. These are plans for those with specific chronic illnesses. Your doctor has to provide documentation and a signature that you have this illness. The plan has benefits to support ongoing care of the chronic illness and may include a Clinical Case Manager, enhanced transportation benefits, etc.
Medical Savings Account
This is a fairly new concept in the state of Indiana but rising in popularity. These Advantage Plans work similarly to a Health Savings Account type of plan. The best part is that the insurance company funds the account for you. And unlike the other Advantage Plans, there is no network. You can see any provider you want to see. You will owe all the cost of services, but you will use the money in the account to pay for it. And there is a Max Out of Pocket. Many of these plans allow you to roll the money over year over year and accumulate. Note, however, there is no drug coverage included, and thus you will need to enroll in a separate stand alone Part D plan.
MA Only Plans
These plans are Advantage Plans that have no prescription drug coverage embedded in the plan. These can be set up as a PPO or HMO. These plan are designed for those that have creditable drug coverage from another source like the VA Administration or a Federal Retiree benefit plan. They also offer some enhanced benefits to take advantage of as long as you have drug coverage elsewhere. You cannot have this plan and enroll in a separate stand alone Part D Plan.
Wrap It Up Please……
Obviously, once you decide you want to go the Advantage Plan route, there are still more choices to be made. Do I get a PPO or HMO? Do I qualify for a Special Needs Plan? Do I also have creditable drug coverage on my plan?
CDI can help you through this entire maze. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
“Happiness is a choice. You can choose to be happy. There is going to be stress in life, but it’s your choice whether you let it affect you or not.”
– Valerie Bertinelli