Congress passed a law in 1997 that implemented new Medicare health plans, called Medicare Advantage, also known as Medicare Part C.  Under the Medicare Advantage option, private companies contract with Medicare to provide health care services to Medicare recipients.  Currently, with nearly 44 million Americans in the Medicare program, over 8 million have chosen Medicare Advantage Options.

 

In these plans, individuals are enrolled in the Medicare system, but their health care benefits are administered by Medicare Managed Care Plans such as:

Medicare pays a set amount to the Medicare Advantage Plan and, in turn, the plan determines the cost reimbursement to the provider, as well as to the insured individual.  All Medicare Advantage plans must offer at least the same services as Original Medicare.  Many offer more, such as eye exams and routine physicals, but sometimes with added costs and restrictions.  Not all areas of the country will offer the same number or type of plans. Benefits, premiums, and co-payments may all change from one year to the next.  You would need to check with the Medicare provider as to the specifics of coverage. 

 

Any individual who opts for a Medicare Advantage plan must have both Medicare Parts A and B prior to enrollment and continue paying the Part B premium while in the Medicare Advantage Plan.  Individuals can generally join a Medicare Advantage Plan that is available in their area when they are first eligible for Medicare or during open enrollment periods between November 15 and December 31 of each year.  They can generally also join or switch Medicare Advantage Plans or switch to Original Medicare between January 1 and March 31 of any year as long as they maintain their Medicare Prescription Drug coverage.  Also, under certain circumstances, individuals may join Medicare Advantage at any time, such as when they move out of the service area that their current plan covers.

 

Medicare Advantage Plans may discontinue their Medicare contract at the end of each year, should they choose to do so.  They must notify their members if they are going to leave the program.  If an individual’s plan stops providing services in his or her area or leaves altogether, the individual has the right to join another Medicare Advantage Plan in the area or return to Original Medicare.

 

If a plan leaves the service area, individuals have a legal right to purchase Medigap policies A, B, C, F, K, or L regardless of their health status unless they are under age 65 and have End-Stage Renal Disease.  The individual must apply within 63 days from when the Medicare Advantage coverage ends.  If the individual is eligible for one of these guaranteed issue Medigap Plans, companies cannot require a waiting period before covering health conditions the person already has or charge more premium than another person of the same age would pay.