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Understand Medicare Part C - Medicare advantage
Part C – Medicare Advantage
MA is a program through which organizations that contract with CMS furnish or arrange for the provision of health care services to Medicare beneficiaries who
: Are entitled to Part A and enrolled in Part B
; Permanently reside in the service area of the MA Plan
; and Elect to enroll in a MA Plan.
Individuals with ESRD are generally excluded from enrolling in MA Plans.
Since 2006, beneficiaries have been able to enroll in regional Preferred Provider Organization (PPO) Plans throughout the U.S. In addition, beneficiaries are able to choose options such as Private Fee-for-Service Plans (PFFS), Health Maintenance Organizations, local PPOs (currently the most popular type of employer-sponsored plan), and Medicare Medical Savings Account (MSA) Plans (combines a high-deductible health plan with a MSA).
MA plans may also offer Medicare prescription drug benefits. Individuals enrolled in MA plans must receive their Medicare prescription drug benefits from their MA plan, except for MA PFFS plans that do not include drug benefits.
Medicare beneficiaries may choose to join or leave a MA Plan during one of the following election periods
: Initial Coverage Election Period, which begins three months immediately before the individual’s entitlement to both Medicare Part A and Part B and ends on the later of either the last day of the month preceding entitlement to both Part A and Part B or the last day of the individual’s Part B IEP. If the beneficiary chooses to join a Medicare health plan during this period, the Plan must accept him or her unless the Plan has reached its member limit
. Annual Coordinated Election Period (AEP), which occurs each year between November 15 and December 31. The Plan must accept all enrollments during this time unless it has reached its member limits.
SEP, when, under certain circumstances, the beneficiary may change MA Plans or return to the Original Medicare Plan.
Open Enrollment Period (OEP), during which time the beneficiary may leave or join another MA Plan if it is open and accepting new members. Elections made during this period must be made to the same type of plan (regarding Medicare prescription drug coverage) in which the individual is already enrolled. The OEP occurs from January 1 through March 31 of every year. If a plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.
Top Medicare billing tips
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