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What is a Medicare Advantage plan?

In order to lessen Original Medicare out-of-pocket costs, some folks on Medicare enroll into Medicare Advantage.

  • These plans are another way to have basic Medicare (Parts A & B) benefits administered by Medicare approved private companies.

Medicare Advantage enrollees enjoy the same features of Original Medicare -plus, reduced and limited out-of-pocket costs.

  • Some Medicare Advantage plans include extra benefits beyond typical benefits covered by Original Medicare -such as routine dental and vision, hearing aids, private duty nurses -and wellness programs.
  • What’s more, Medicare Advantage plans usually include Medicare Part D prescription drug coverage too.

Let Medicare Advantage Work for You.

If you want to sign-up for Medicare Advantage, eligibility requirements are more restrictive than simply having Original Medicare.

  • Medicare Advantage enrollees must live within their chosen plan’s service area and agree to follow unique plan rules -for instance, getting non-emergency treatments locally, and preferably from in-network providers.

Are you aware..? Medicare Advantage provides life threatening emergency and/or urgent care, anywhere in the country without network restrictions.

  • In emergency or urgent situations, just go to the nearest urgent care clinic -or closest hospital emergency room, and present your Medicare Advantage ID card.
  • All acute care facilities are familiar with Medicare guidelines, and aware they’re obligated to treat Medicare Advantage members -when it’s medically necessary.

Bye the way, Medicare Advantage (sometimes referred to as Medicare Part C) isn’t Medigap coverage.

  • Medicare supplement helps pay Original Medicare out-of-pocket costs -such as deductibles, copays and coinsurance.
  • Whenever you have Medigap coverage and sign up for Medicare Advantage, you can’t use your Medigap policy -because, Medicare supplement doesn’t coordinate with Medicare Advantage.

Medicare Advantage is a viable option for anyone living on limited income -because, Medicare Advantage plans usually have cheaper premiums than Medigap policies.

  • Equally important, Medicare Advantage usually includes Medicare Part D prescription drug coverage, allowing members to conveniently package Medicare benefits together.

Key Medicare Advantage Benefits.

Whenever you first sign-up for the federal Medicare program you’ll have Original Medicare, unless you make another choice.

There are two ways Medicare coverage can be administered:

  1. Stay on Original Medicare -and consider joining a Medicare prescription drug plan. Because, unless you have creditable drug coverage, you may have to pay a late enrollment penalty whenever you join later.
  2. Choose to join Medicare Advantage, like an HMO, PPO, or PFFS plan -if one’s available in your area.

Since, Medicare Advantage usually includes prescription drug coverage, in most cases you’ll have to use drug coverage offered within your chosen plan.

  • Except: Medicare Advantage PFFS-MA only members can have stand alone drug coverage jointly.

It’s important to consider all viable options.

You don’t need to sign-up for Medicare every year -but, you will have a chance to review Medicare Advantage, and Medicare prescription drug plans, available in your area, during Medicare Annual Election Period each fall.

  • Between October 15th and December 7th -and your new coverage will start the following January 1st.

Here are a few things to consider while you’re choosing the ideal benefit package.

  • Cost: With Original Medicare there’s no limit on out-of-pocket costs, unless you buy a Medigap policy.
    • Medicare Advantage limits annual out-of-pocket exposure.
      • Once you reach the plans annual limit, you’ll pay nothing for covered services for the rest of that year.
  • Basic Coverage: Original Medicare covers necessary medical treatments and supplies received from providers who accept Medicare patients.
    • Medicare Advantage plans must cover everything Original Medicare covers.
      • Typically, Medicare Advantage plans have network providers.
      • In addition, some plans offer benefits Medicare doesn’t cover, like routine dental and vision, hearing aids, and wellness programs.
  • Supplemental coverage: You can buy a Medigap policy to help pay out-of-pocket costs of Original Medicare -like deductibles, copays, and coinsurance.
    • Joining Medicare Advantage may be more cost effective; because cost sharing is reduced and limited.
      • You can’t be sold, and can’t use a Medigap policy while you’re enrolled in Medicare Advantage.
  • Prescription drug coverage: You’ll need to join a Medicare prescription drug plan to get Part D drugs covered.
    • Again, most Medicare Advantage plans include prescription drug coverage.

Some people need help paying Medicare costs.

Medicare Savings Programs:

Anyone on Medicare with limited income and resources may be able to get help from their state to pay Medicare related costs -if certain conditions apply.

To find-out about available programs in Texas, contact Texas Health and Human Services at: – Or, call 1-877-541-7905.

One of these four Medicare Savings Program levels may help:

  1. Qualifying Individual (QI): Helps pay your Part B premium. You must apply each year for QI benefits. Applications are granted on a first-come first-served basis.
  2. Specified Low-Income Medicare Beneficiary (SLMB): Helps pay your Part B premium.
  3. Qualified Disabled and Working Individuals (QDWI): Only helps pay Part A premiums. If you have a disability, but still work, you may qualify for this program.
  4. Qualified Medicare Beneficiary (QMB): If you’re eligible, the QMB Program helps pay Parts A and/or B premium(s).

Beware, whenever you have QMB, doctors and most other providers aren’t allowed to bill you typical Medicare copays -like deductibles, copayments, or coinsurance.


  • On the other hand, pharmacies can charge limited copays for Medicare Part D prescriptions, up to $3.70 in 2018, while you’re QMB eligible, because anyone eligible for QMB automatically qualifies for Extra Help paying for prescription drugs.
  • To assure providers you have QMB, show both your Medicare ID (or Medicare Advantage plan ID) and your QMB card, whenever you receive Medicare approved treatments -or, Part D drugs.

If you get inaccurately billed, notify the provider about your QMB status.

  • If you have Original Medicare, show the provider your Medicare Summary Notice, to confirm QMB eligibility and verify you shouldn’t be billed.
  • If that doesn’t fix your billing issue, call 1-800-MEDICARE. They will ask the provider to stop improper billing, and urge them to refund incorrect payments you’ve made.
  • If you have Medicare Advantage -call your plan.

Beyond that, in case you join Medicare Advantage, you’ll still have basic Medicare benefits -but, your chosen plan, instead of Medicare, pays its share for medically necessary treatments and supplies.

Medicare pays these private companies a fixed monthly amount to administer covered services.

  • So, Medicare Advantage plans must follow strict rules set by Medicare.

Each Medicare Advantage plan can change out-of-pocket costs, and may also have different rules for how and where you get services like:

  • Getting a referral to see a specialist
  • Going to doctors, facilities, and suppliers that are in the plans network of providers for non-emergency or non-urgent care.

What’s more, provider networks can change throughout the year, under limited circumstances.

Medicare Advantage rules can change each year.

  • It’s important to review your “Annual Notice of Change” and “Evidence of Coverage” that your plan must send you every year, before the start of the next Medicare Annual Election Period.
  • Remember, you have the option to decide whether you want to keep your current plan, choose another Medicare Advantage Plan, or switch to Original Medicare every year during Medicare AEP.

Medicare Advantage plans have unique features:

  • Does the plan charge a premium -in addition to your Medicare Part B premium?
    • You must have both Medicare Parts A & B, and live in the plans service area, to sign-up for Medicare Advantage.
  • Does the plan have deductibles for certain services?
  • How much will you pay for provider visits and/or services
    • Copays, and/or coinsurance.
  • Does the plan help pay any part of your Part B (or Part A, if you have to buy it?) Premium(s)?
  • What’s your chosen plan yearly maximum out-of-pocket limit for all medical services and supplies?
  • If you want extra benefits, does the plan include them?
  • If you’re enrolled in a PPO, Private Fee-for-Service, or an HMO-POS Medicare Advantage Plan, are you using out-of-network providers who accept Medicare Assignments?

You have certain rights, if your Medicare Advantage or prescription drug plan ever stops participating in Medicare.

Medicare Advantage and prescription drug plans can decide not to participate in Medicare for upcoming years.

  • If this happens, your coverage ends accordingly December 31st.
    • You’ll be able to choose another plan during Medicare Annual Election Period. (Between October 15th through December 7th)
      • Your new coverage will begin the following January 1st.

What’s more, you’ll have a “special right” to join another Medicare health or prescription drug plan until February 28th, the following year.

To learn more about your costs in specific Medicare Advantage plans, call our local office at: 806-350-7380 during normal business hours. We’ll get you headed in the right direction in minutes. That’s kinda what we do here – Keep in mind, our local advocacy services are always FREE, and there’s never any obligation to enroll.

Copyright by Medicare Amarillo 2019.