Medicare Guide

Types of Medicare Advantage Plans

You can generally join one of the following types of Medicare Advantage Plans:

1. Health Maintenance Organization (HMO)

2. Preferred Provider Organization (PPO)

3. Private Fee-for-Service (PFFS)

4. Medical Savings Account (MSA) Plan

Eligibility Requirements

To join a Medicare Advantage Plan, all of these must apply:

• You live in the service area of the plan you want to join. The plan can provide more information about its service area. If you spend part of the year in another state, ask if the plan will cover you there.

• You have Medicare Part A and Part B.

• You do not have End-Stage Renal Disease (ESRD).

Medicare Advantage Plans (Part C)

Medicare Advantage Plans, also known as “Part C” or “MA Plans,” provide an all-in-one alternative to Original Medicare. Offered by private companies approved by Medicare, these bundled plans include:
✔ Medicare Part A (Hospital Insurance)
✔ Medicare Part B (Medical Insurance)
✔ Usually Medicare Part D (Prescription Drug Coverage)

What’s Covered?

Medicare Advantage Plans cover all services included in Original Medicare. Some plans also offer extra benefits like:
🔹 Vision
🔹 Hearing
🔹 Dental

Plan Rules & Costs

Medicare pays a fixed amount each month to companies offering Medicare Advantage Plans. Each plan sets its own out-of-pocket costs and may have different rules, such as:
✔ Requiring referrals to see specialists
✔ Limiting care to in-network providers

Rules & costs may change each year. Contact us to learn more.

Drug Coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include prescription drug coverage (Part D). However, certain plans:
🔹 Cannot offer drug coverage (like Medicare Medical Savings Account plans)
🔹 Choose not to offer drug coverage (like some Private Fee-for-Service plans)

If you’re in an HMO or PPO Medicare Advantage Plan and join a separate Medicare Prescription Drug Plan, you’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.

Medicare Supplement Insurance (Medigap) & Medicare Advantage

Medigap policies cannot be used with Medicare Advantage Plans. To learn more about your options, contact Total Care Consultants.

How to Switch Your Medicare Advantage Plan

If you're already enrolled in a Medicare Advantage Plan and want to switch, follow these steps:

Switching to a New Medicare Advantage Plan

1. Join the new plan during one of the Medicare enrollment periods.

2. You’ll be automatically disenrolled from your old plan when your new plan’s coverage begins.

Switching to Original Medicare

1. Contact your current plan or reach out to Total Care Consultants to assist with the process.

Important Considerations

• Medicare Prescription Drug Coverage (Part D): If you don’t have other drug coverage, you should consider enrolling in Part D.

• Medicare Supplement Insurance (Medigap): You may also want to explore Medigap policies to help with additional costs.

• Switching Timeframe: You can only switch during certain enrollment periods.

If You Have Other Coverage

• Before joining a Medicare Advantage Plan, talk to your employer, union, or other benefits administrator about your options.

• Potential Coverage Loss: Joining a Medicare Advantage Plan might cause you to lose your employer or union coverage. If you lose coverage, you might also lose coverage for your spouse or dependents.

• In some cases, you may still be able to use employer or union coverage alongside the Medicare Advantage Plan, but dropping it may prevent you from getting it back.

At the end of the year, Medicare Advantage Plans can choose to leave the Medicare Program. If this happens, you will receive a letter explaining your options.

Your Options if Your Plan Leaves Medicare:

✅ Automatically Return to Original Medicare – If you don’t select a new Medicare Advantage Plan, you’ll be automatically enrolled in Original Medicare (Part A & Part B).

✅ Right to Buy a Medigap Policy – You may be eligible to purchase a Medicare Supplement (Medigap) policy to help cover additional costs.

✅ Medicare Prescription Drug Coverage (Part D) – If you return to Original Medicare, you’ll need to decide if you want prescription drug coverage. To get this, you must enroll in a Medicare Prescription Drug Plan (Part D) separately.

⚠️ No Matter What You Choose: You’ll remain in the Medicare Program and continue receiving all Medicare-covered services.

Need help exploring your options? Contact us today!

Medicare Advantage & End-Stage Renal Disease (ESRD)

If you have End-Stage Renal Disease (ESRD), you’ll usually receive health care through Original Medicare. However, you may be able to join a Medicare Advantage Plan (Part C) in specific situations:

Who Can Join a Medicare Advantage Plan with ESRD?

✅ You were already enrolled in a Medicare Advantage Plan before developing ESRD. You may be able to stay in your plan or switch to another plan offered by the same company.

✅ You receive health benefits through an employer plan that is offered by the same organization providing the Medicare Advantage Plan.

✅ You had ESRD but received a successful kidney transplant. If you still qualify for Medicare based on age or disability, you can stay in Original Medicare or join a Medicare Advantage Plan.

✅ A Medicare Special Needs Plan (SNP) for ESRD may be available in your area.

One-Time Right to Change Plans

You have a one-time right to switch to another Medicare Advantage Plan if both of these apply:
🔹 You have ESRD and are currently enrolled in a Medicare Advantage Plan.
🔹 Your plan leaves Medicare or stops offering coverage in your area.

⚠️ Important: You don’t have to use this option immediately. If you return to Original Medicare after losing coverage, you still have a one-time right to join a Medicare Advantage Plan later.

Need help understanding your options? Contact us today to find the right plan for you!