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Exactly what are Medicare Advantage plans?

Falling under Medicare Part C, Medicare Advantage plans (MAPD) were created by Congress to give Medicare beneficiaries a lower premium option than a Medicare Supplemental.

Basically, they are private health insurance plans that you can sign up to as an alternative to Original Medicare. These plans offer all the same services as Original Medicare, and most plans also include the following benefits: Routine dental, vision, hearing aids + care, etc..

Our insurance agency proudly serves the residents of Broward (BC), Duval, Marion, Monroe, Miami-Dade, Orange, and Palm Beach counties.

Our office is located less than a mile from Downtown Hollywood, across the Big Easy Casino on Pembroke Road.

Additional benefits to enrolling in a Medicare Part C plan

  • FREE gym membership through the SilverSneakers program.
  • Most Medicare Advantage plans include a prescription drug plan;
  • Most of your coinsurance percentages are converted to flat copays;
  • Annual maximum out of pocket spending limit for each MAPD plan;
  • Supplemental benefits such as: transportation, OTC items, **housecleaning.

**Applies to beneficiaries with chronic diseases. For example, if someone has asthma, getting their carpet cleaned might keep them out of the hospital.

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Eligibility, monthly premiums, deductibles, and limits

Eligibility

You must continue to be enrolled in both Medicare Part A and B, pay your monthly part B premium, live in the service area of the plan, and not be diagnosed with end-stage renal disease (ERSD).**

**You won’t qualify for most Medicare Advantage plans (Part C), except for one type of special needs plan, which was created specifically for people with ERSD.

Monthly premium

You must continue to pay your part B premium to become eligible for a Medicare Advantage plan.

According to the Kaiser Family Foundation, the average Medicare Advantage (Part C) premium in 2019 is $29, which is slightly lower than it has been the past five years.

HMO premiums tend to be lower than the regional and local PPOs and significantly vary across the different counties.

*At least one Medicare Advantage plan tends to be $0 premium in most counties, so check out the list of plans with your health insurance broker.

Deductibles

Medicare Advantage HMO plans tend to waive the Part B and Medicare Part D deductibles (sometimes). PPO, SNP, and POS plans tend to waive the Part B deductible, but not the Medicare Part D deductible (which can be up to $415, the maximum allowable under the law).

Limits

The maximum out of pocket limit is the total amount an enrollee will spend yearly on a copay, coinsurance, and other costs for medical services.

Once you reach your annual limit, your Medicare Advantage (Part C) plan’s eligible medical services are covered at no cost to you for the remainder of the year.

The maximum out of pocket responsibility for the average Medicare Part C enrollee is $5,059 (HMO and PPO) and $8,818 for out of network services (PPO) according to the Kaiser Family Foundation.

*Reaching your maximum out of pocket limit does not affect your Medicare Advantage plan’s prescription drug coverage.

Find out more information about Medicare Advantage plans (Part C).

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Comparing different types of Medicare Advantage plans

HMO: Health maintenance organizations (HMO) have an established provider network and only cover services by an in-network provider. The coverage map for these type of plans are no smaller than a county.

PPO: Preferred provider organizations (PPO) have an established provider network and allow the enrollees to receive medical care outside of the network. The cost sharing will be much higher for the medical care received outside of the network. Coverage map for these type of plans are also no smaller than a county.

*According to the Kaiser Family Foundation 62% of Medicare Advantage enrollees are in a HMO and 31% in a PPO.

SNP: Special Needs Plans (SNP) are HMOs that are restricted to beneficiaries who: (1) are dual eligible for Medicare and Medicaid; (2) reside in long-term care institutions or that require institutional levels of care; or (3) have certain chronic conditions.

PFFS: Private For Fee Service Plans (PFFS) determine how much it will pay doctors, hospitals, and other medical services and how much the enrollee themselves will also pay.

Most of these plans do not have an established physician network, therefore you can see any doctor or hospital who accepts Medicare and the terms and conditions of your separate Part D plan.

Group Plans: Sponsored mainly by employers and unions for retirement. The employer or union is contracted with an insurer that then provides Medicare benefits and additional retiree health benefits.

Covered health benefits

Doctor visits

Receive preventative care (at no cost to the enrollee) with an in-network provider and visit your primary care physician and specialists.

Hospitals

Inpatient hospital admissions and stays (prior authorization may be required) and the emergency room are covered.

Outpatient surgery

Surgery services are covered at an outpatient hospital and ambulatory surgical center (prior authorization may be required).

Urgent care

Immediate medical care will be provided to treat a non-emergency, unforeseen medical illness, injury or condition.

Diagnostics and labs

Imaging, lab services, diagnostic services, outpatient x-rays, and radiation therapy (prior authorization may be required)

Hearing

Medicare covered hearing care, routing hearing exams, hearing aid fitting + evaluation, and hearing aids.

Dental

Medicare covered dental services, preventative and *comprehensive dental services *(prior authorization may be required).

Vision

Medicare covered vision care (prior authorization and referral may be required), routine vision, and eyewear.

Mental / Substance

Inpatient (prior authorization may be required), outpatient mental health, and outpatient substance use visit.

Prescription drugs

Medicare Part B drugs, 30 day supply network retail pharmacy, 90 day supply network mail order, and erectile dysfunction drugs.

Miscellaneous

Skilled nursing facility (prior authorization may be required), ambulance, and transportation services.

Additional services

Dialysis, foot care, home health care, rehab services, meals, FREE gym membership, over the counter items, acupuncture, etc..

Contact us today to see which medicare advantage plan is right for you.

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Medicare Part D (prescription drug plans)

During the Annual Enrollment Period (AEP) beneficiaries may enroll in a Medicare Advantage plan that includes prescription drug coverage (mainly HMO and PPO), also known as Medicare Part D. In 2019, 90% of Medicare Advantage plans offer prescription drug coverage.

How does Part D work?

1.

Annual deductible

The Medicare Part D deductible for 2019 is $415, some Medicare Advantage plans charge either the full deductible, partially, or waive it in its entirety.

You start paying the mixture of coinsurance and copays for your medications once you have satisfied your plans deductible (if necessary).

2.

Initial coverage

Once you enter this stage you will pay modest copays for generic drugs and higher copays for brand name drugs in 2019. The coinsurance applies towards non-preferred and specialty drugs.

Preferred generics usually range from $0 – $5, generics from $1 – $13, preferred brand name from $25 – $47, non-preferred brand name range from 32% – 50%, and specialty drugs range from 25% – 33%.

The insurance company keeps up to date with theirs and your spending, until the $3,820 limit is reached.

3.

Coverage gap (Medicare Part D Donut Hole)

Reaching the $3,820 initial coverage limit for 2019 will place you in the coverage gap or Medicare Part D donut hole.

Throughout your time in the gap, you, as an enrollee, will pay 25% coinsurance for generic drugs and 37% coinsurance for  brand name drugs.

You will remain in the gap until your out of pocket drugs costs reach $5100 in 2019.

Medicare considers paying the deductible, co-pays, and manufacturer discounts as part of your drug costs in order to get out of the gap.

4.

Catastrophic coverage

After you have gotten out of the coverage gap, your Medicare Advantage plan will pay 95% of your drug costs for the rest of the year.

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Advantage of Using an El Mag Insurance Health Broker

Our tagline says it all; ‘Our plans are based on yours.’ El Mag Insurance is dedicated to helping our clients meet their specific insurance coverage needs.

We live in an uncertain world and insurance coverage must often be tailored to offer specific solutions for individual risks.

Maximized Savings

Asking pertinent questions that familiarize ourselves with your situation so we can continually assess both the ideal plan, but also the long term savings for you, the client.

Claim Assistance

Accidents occur everyday and having a health insurance broker be your advocate during the claims process is to a client’s benefit (both mentally and time constraint wise).

Risk Assessment

We will never rush you into a decision. Our work ethic dictates that we take as much care as we possibly can to match you with the ideal insurance policy for you and your loved ones.

Quality Coverage

The comprehensive pallet of private insurance plans offered provide a customized protection solution that caters to you and your family’s health, liability, or property coverage needs.

Personal Support

View this as a partnership between yourself and our agency; this client-focused approach has helped us gain thousands of satisfied and loyal clients all around the state of Florida.

Knowledge

The years of experience that our health insurance brokers possess allows us to be knowledgeable about an insurance company’s individual strengths and weaknesses.

Contact one of our independent insurance agents today to set up a medicare advantage consultation.

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Company overview

El Mag Insurance is a family-owned (think of My Big Fat Greek Wedding) independent insurance agency that serves the awesome residents of The Sunshine State, specifically the counties of: Broward, Duval, Marion, Monroe, Miami-Dade, Orange, and Palm Beach counties.

Reading or talking about insurance in general can be both tedious and confusing (we know) for many individuals.

Continuous improvement is a large part of our agency’s philosophy, and implementing a more streamlined and less tiresome way to engage with both prospects and clients has been one of our goals since our founding in 2015.

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