Medicare Advantage

Despite the fact that most Arizona seniors work hard to stretch every penny, many have just a little bit too much income to qualify for AHCCCS Medicaid.  Our ACCESSMed volunteers help these individuals understand and take advantage of low cost Medicare Advantage options.

Coordinated Care

In addition to being cost-effective, many Medicare Advantage plans coordinate care between your health care providers. They combine medical, Part D prescription drug coverage, and some of additional benefits including coverage for routine vision care, hearing aids, routine dental care, prescription drugs and fitness center memberships.

Medicare Advantage health insurance plans are provided by private health insurance companies (rather than the federal government). There are four types of plans:

• Healthcare Maintenance Organizations (HMO’s)
• Preferred Provider Organizations (PPO’s)
• Private Fee-for-Service plans (PFFS)
• Medical Savings Accounts (MSA’s).

Medicare Advantage HMO’s

HMO’s are managed health care systems that work to decrease costs for healthcare consumers. They frequently work with businesses that want to offer economical health insurance to a number of employees.

Advantages

HMO’s generally provide economical coverage as an adjunct to Medicaid and also for privately insured patients. Some HMO policies have a zero monthly premium. Most have relatively low out-of-pocket costs for prescriptions.

Disadvantages

HMO’s require participants to stay within their network. If your doctor is not in their network (or leaves it), you have to find a new primary care provider. In addition, most require a co-payment for each visit. And, unapproved non-emergency in-network and all out of network specialist visits are generally uncovered. Patients who require highly specialized treatment may find that their treatment is not available in-network (and, as a result, may be unaffordable).

Medicare Advantage PPO’s

A PPO Medicare Advantage plan is generally more expensive versus an HMO plan but is also more flexible.

Advantages

A PPO Medicare Advantage plan provides more flexibility to see doctors both in and out of network. Patients are not required to have a primary care provider and they are free to see specialists without referrals.

Disadvantages

PPO plans are more expensive versus HMO plans.

Private Fee-for-Service

Some PFFS plans have provider networks. Others allow patients to receive care from any hospital or doctor that accepts the plan’s coverage. Most plans do not require a referral from a primary care doctor in order to see a specialist and some plans include prescription drug coverage.

Advantages

You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms and agrees to treat you.

Disadvantages

PFFS plans are generally more expensive than HMO and PPO plans. Out-of-network doctors, hospitals, and other providers may not be contracted with a PFFS plan and will not accept the plan’s payment terms.

Medicare Advantage Enrollment

While Medicare Advantage insurance can be an economical alternative to Medicaid, getting signed up requires a little timing. Depending on your personal situation, you have to apply during an enrollment period that you qualify for.

Initial Enrollment

Your initial enrollment period starts three months before your 65th birthday and ends three months after it.

Annual Enrollment

If you do not sign up for Medicare Advantage during your Initial Enrollment period, you can sign up at any age during the Open Enrollment period which runs from October 15 through December 7. You can also move from one plan to a different one during this period.

Open Enrollment

The Open Enrollment period runs from January 1 of each year, through March 31. During this period people who are currently enrolled in a Medicare Advantage plan can move to a different plan or drop their coverage entirely.

Special Enrollment

During this period, people who have chronic medical conditions or who have experienced significant life changes may be able to enroll in a Medicare Advantage plan or move from one plan to a different plan.

In Arizona, qualifying chronic conditions include congestive heart failure, diabetes, high cholesterol, high blood pressure and others. Significant life changes may include moving to or out of an institution (such as a nursing home), moving outside of your current Medicare Advantage plan’s service area, losing employer provided or other health insurance coverage or being released from prison.