How Medicare Advantage Plans Work

These are the general rules for how Medicare managed care plans work. For some of these rules, plans may differ slightly, so it is important to call your plan.

Costs

You generally still pay the Part B monthly premium. This is the premium that is withheld from your monthly Social Security check. You also pay the Medicare Advantage Plan's premium (if they charge one) that includes coverage for Part A and Part B benefits, prescription drug coverage (Part D, if offered), and any other extra benefits (if offered).

You usually will have to pay some other costs (such as copayments, deductibles, or coinsurance) for the services you get. Out-of-pocket costs in these plans vary by the services you get. Check with your plan before you get a service to find out what your costs may be.

Providers

Your choice of doctors and hospitals varies by the type of Medicare managed care plan you choose. In most Medicare managed care plans, there are doctors and hospitals that join the plan (called the plan's network). You will likely need to get most of your care and services from the plan's network. Call the plan to see which doctors and hospitals are in the plan.

Some Medicare managed care plans offer a Point-of-Service option. This allows you to go to other doctors and hospitals who are not a part of the plan (out-of-network), but may cost extra.

Doctors can join or leave Medicare managed care plans at any time. If your doctor should leave your plan, you will be notified in advance and given the chance to pick a new doctor.

Primary Care Physician

When you join a plan, you may be asked to choose a primary care doctor. To control costs, the HMO arranges with a network of health care providers to furnish all necessary services and requires members to obtain services from those providers. You must choose a primary care physician from the Medicare managed care plans list of participating doctors. Your HMO primary physician is responsible for coordinating and providing most or all of your care. If you already have a doctor you would like to keep seeing, ask your doctor if he or she is in the plan and accepting new patients under the plan.

Changing Your Primary Care Physician

If you want to change your primary care doctor, you can ask your plan for the names of other plan doctors in your area.

Doctors can join or leave Medicare managed care plans at any time. If your primary care doctor should leave your plan, your plan will notify you in advance and give you a chance to pick a new doctor.

Referral

A referral is permission from your primary care doctor to see a medical specialist or receive specialty care services. Your primary care physician is responsible for referring you to all specialists if the plan is to pay for all the specialist's services.

There are special rules for certain services. For example, if you are a woman, you can go once a year, without a special referral, to a specialist in the network for routine and preventive woman's care services. If the specialist you need isn't available, the plan will arrange for care outside the network.

Care Outside of Service Area

If you get health care outside the service area of the plan, you may pay more or it may not be covered. The service area is where the plan accepts members and where to get services from the plan.

Your Medicare Advantage plan may have a passport plan* provision allowing you to see providers in other parts of the country, if the plan provides this benefit.

Plan benefits may change each year. The plan will send you an Annual Notice of Change each fall. This notice has information about any changes in benefits, costs, or service area that will be effective in January. If the plan covers prescription drugs, the notice will include changes to the formulary. You should review this notice carefully to learn about changes for the upcoming year to decide if you want to look at other plans in your area.

If the plan decides to no longer participate in the Medicare program, you will have to join another Medicare Advantage Plan or return to the Original Medicare Plan.

*Passport Plan: A passport plan provision is defined as a network of providers who are outside of your plan's service area, usually in a different state, which can be used by you in non-emergency or urgent care. Plans have these networks available to individuals who travel to certain states. Check with your plan on the availability of this provision.