You may have the option to join a Medicare Advantage plan (formerly called Medicare + Choice or Medicare Part C).
CMS enters into annual contracts with insurance companies and managed care plans to provide Medicare Advantage coverage. Medicare Advantage plans include health maintenance organizations (HMOs), preferred provider plans (PPOs), private fee-for-service plans (PFFS), special needs plans, and medical savings accounts.
You can only join a Medicare Advantage plan if a plan is available in your area and you have Medicare Part A and Part B. Some plans may have additional eligibility requirements. Plans provide their members with a handbook upon enrollment that outlines the complaints and appeals process for denial of services.
Medicare Advantage plans might offer additional benefits and be cheaper than original Medicare. However, they’re not right for everyone. Your choice of providers in a Medicare Advantage plan may be restricted. Some plans will require you to use doctors and other providers in their “networks” for routine, nonemergency care. For other types of plans, your providers must agree to accept the plan’s terms and conditions before treating you.
Depending on where you live, you may have the option to choose between Medicare or a Medicare Advantage plan. If you are in a Medicare Advantage plan, you don’t need a Medigap policy. Medicare Advantage plans provide at least the same benefits as Medicare.
There are several types of Medicare Advantage plans:
managed care plans, which include HMOs, PPOs, provider-sponsored organizations, and religious fraternal benefit society plans
private fee-for-service plans
special needs plans
Medicare medical savings accounts.
Medicare pays a monthly premium to the Medicare Advantage plan to provide your health care. The plan may require you to pay an additional premium and may charge you a copayment each time you go to the doctor or get a prescription.
To join a Medicare Advantage plan, you must have both Medicare parts A and B and live in an area that has a plan. Some plans have other eligibility criteria. Not all plans are available in all areas of the state. Call Medicare or visit the Medicare web page and select the Compare Health Plans and Medigap Policies in Your Area interactive page. You may also call TDI’s Consumer Help Line to learn which plans are available in your area.
Medicare HMOs typically require you to use only physicians and hospitals in the HMO’s network. A Medicare HMO with a point-of-service option allows you to choose your own doctors, but you will have to pay extra. With a private fee-for-service plan, you can generally go to any doctor or provider and receive care anywhere in the United States. The doctor and provider, however, must agree to treat you and to accept the plan’s payment terms.
If your Medicare Advantage plan terminates its contract in your service area, you have the right to purchase Medigap plans A, B, C, F, K, or L offered in Texas without regard to your medical history or condition. If your Medicare Advantage plan ends services in your area, it must explain to you in writing your options and timeframes to buy a Medigap policy.
