The US health insurance system offers a variety of coverage options, designed to give citizens a peace of mind and reassurance when it comes to their healthcare costs. Medicare is the national health insurance program for seniors, instituted in the mid 1960s. You can get your health coverage through Original Medicare. You can also consider the Arizona Medicare Advantage plans as your coverage choice.
How do Arizona Medicare Advantage Plans and Medicare work?
Medicare addresses the needs of senior citizens aged 65 and above who have worked and paid their social security benefits and taxes. It’s administered by the federal government through around 30 private insurance providers across the country.
Medicare also provides coverage for people under 65 with certain qualifying disabilities and people with permanent kidney failure and amyotrophic lateral sclerosis of any age.
Different parts of Medicare cover different healthcare aspects. Original Medicare has two parts – A and B.
Medicare Part A (hospital insurance) covers inpatient care in hospitals, skilled facilities, hospice and home healthcare.
Medicare Part B (medical insurance) covers the costs of doctor visits, outpatient care, durable medical equipment, certain preventive services and eligible home health services.
Medicare Part C (Medicare Advantage or MA) is designed as a substitute for Original Medicare. It includes all benefits and services covered by Parts A and B. Medicare Prescription Drug Coverage (Part D) is usually bundled into the plan. MA is run by private companies approved by Medicare.
Medicare Part D subsidizes the costs of prescription drugs and drug insurance premiums for Medicare beneficiaries. It’s administered through Medicare-approved private insurance companies.
You can get your Medicare coverage through Original Medicare or you can join a Medicare Advantage Plan.
Types of Medicare Advantage Plans
Health Maintenance Organization (HMO) plans: Your choice in most HMOs is limited to doctors and hospitals within the plan’s network (except in case of emergency). You may need a referral for specialist visits.
Preferred Provider Organization (PPO) plans: Using doctors and hospitals within the plan’s network will cost you less. However, you do have the option to receive medical care outside the network at a higher cost.
Private Fee-for-Service (PFFS) plans: As a plan beneficiary, you can use the services of any healthcare provider or hospital willing to treat you, similar to Original Medicare. The plan sets the costs it will cover for doctor visits and treatments, as well as the amount you will pay for your care.
Special Needs (SNPs) plans: SNPs provide care solely to people with specific conditions and characteristics, so that their needs can be met in the best possible way. This includes people suffering from severe or disabling chronic conditions, nursing home residents, or people eligible for both Medicare and Medicaid.
HMO Point-of-Service (HMOPOS) plans: These plans offer certain services outside the network for a higher copayment or coinsurance.
Medical Savings Account (MSA) plans: These plans combine a high-deductible plan with a bank account. Medicare deposits money to the account and beneficiaries use this amount to pay for healthcare services. Medicare drug coverage is not provided under these plans.
Important facts about Medicare Advantage
If you choose to join a Medicare Advantage plan, you will still be in the Medicare program. The difference is that you’ll be getting your Medicare Part A and B coverage from the Medicare Advantage Plan instead of the Original Medicare.
Medicare Advantage Plans cover all services available under Original Medicare, with the exception of hospice care. For Medicare Advantage beneficiaries, this type of care is covered by Original Medicare.
All Medicare Advantage plans cover emergency care.
In addition to the Part B premium, Medicare Advantage beneficiaries usually pay a monthly premium. Each month, Medicare transfers a fixed amount for your coverage to the Medicare Advantage providers.
Keep in mind that each MA Plan can have different out‑of‑pocket costs and rules regarding its services. These rules can change every year.
Your provider is obligated to notify you of any changes prior to the start of the next enrollment year (Annual Notice of Change).
Providers can join or leave your plan’s network anytime during the year. Also, your plan can change the providers in the network. In such a case, you may need to choose a new provider.
Medicare Advantage Plans can’t charge more than Original Medicare for certain services. This includes chemotherapy, dialysis and skilled nursing facility care.
Once you reach the yearly limit on your out-of-pocket costs for medical services set by the plan, you won’t pay anything for services. This limit may differ between Medicare Advantage plans and may be subject to annual changes, so make sure you do your research on this issue.
You can join or leave a Medicare Advantage Plan at certain times during the year. There are specific windows and rules, for example when you first become eligible for Medicare or if you get Medicare due to a disability. Between October 15 – December 7, anyone with Medicare can join, switch or drop a Medicare Advantage Plan.
Each year, MA Plans can choose to leave Medicare or make changes to their costs and services. If your plan decides to withdraw from Medicare, you’ll have to join another MA Plan or return to Original Medicare.
What are the benefits of Medicare Advantage
- Comprehensive coverage from a single source.
- MA plans have the potential for lower premiums compared to the total sum you would pay for Part D and a Medigap plan combined.
- Some Medicare Advantage plans include benefits not covered by Medicare, such as dental, eye care and wellness.
What are the drawbacks of Medicare Advantage
- Your healthcare choices may be limited to the doctors and hospitals within the plan’s network.
- If you choose to get medical care outside the network, you may be responsible for 100% of the costs.
- There may be a copay required each time you get medical treatment.
When choosing healthcare coverage, check if your area of residence is covered by the MA plan you’re considering.
If you have doctors or specialists whose care you prefer, check to see if they’re in the network.
Also, make sure to consult independent sources, since many sites are sponsored and therefore not objective. It’s best to consult the Medicare websites or those of non-profit organizations supporting the interests of seniors.