Medicare Advantage Glossary
- Medicare Advantage (MA) plans, also known as Medicare Part C, offer a different way to recieve your Medicare benefits.
- Choosing the right Medicare Advantage plan requires understanding a specific set of terminology.
- The AEP, running from October 15th to December 7th each year, is the primary time to enroll in, switch, or drop a Medicare Advantage plan.
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Understanding Medicare Advantage Plans
Medicare Advantage (MA) plans, also known as Medicare Part C, offer a different way to recieve your Medicare benefits. Instead of directly accessing services through customary medicare, you enroll in a private insurance plan approved by Medicare.These plans are designed to provide all the benefits of Original Medicare (Parts A and B) and often include extra coverage like vision, dental, and hearing.
Choosing the right Medicare Advantage plan requires understanding a specific set of terminology. This glossary breaks down common terms to help you make informed decisions.
Key Medicare Advantage terms
Annual Enrollment Period (AEP)
The AEP, running from October 15th to December 7th each year, is the primary time to enroll in, switch, or drop a Medicare Advantage plan. Changes made during this period take effect January 1st of the following year.
Benefit Period
A benefit period begins the day you enroll in a Medicare Advantage plan and ends December 31st.Your costs and coverage may change at the start of each benefit period.
Capitation
A payment method where the Medicare Advantage plan receives a fixed amount of money per member per month to cover their healthcare costs.This incentivizes plans to focus on preventative care and manage costs effectively.
Copayment (Copay)
A fixed amount you pay for a covered healthcare service, typically when you receive care. Copays vary by plan and service type.
coinsurance
Your share of the costs for a covered healthcare service, calculated as a percentage of the Medicare-approved amount. For example, a 20% coinsurance means you pay 20% of the bill, and the plan pays the remaining 80%.
Deductible
The amount you must pay out-of-pocket for covered healthcare services before your plan begins to pay. Deductibles can vary significantly between plans.
Formulary
A list of prescription drugs covered by the Medicare Advantage plan. Plans are required to cover a wide range of medications, but formularies can differ, so it’s crucial to check if your medications are included.
HMO (Health Maintenance Organization)
An HMO plan generally requires you to choose a primary care physician (PCP) who coordinates your care and provides referrals to specialists. You typically need to stay within the plan’s network to receive coverage, except in emergencies.
PPO (Preferred Provider Organization)
A PPO plan offers more adaptability then an HMO. You can see doctors and specialists both in and out of the plan’s network, but you’ll generally pay less when you stay in-network. Referrals are usually not required.
The monthly fee you pay to be enrolled in a Medicare Advantage plan. Premiums can vary widely depending on the plan’s benefits and coverage.
Provider Network
The group of doctors, hospitals, and other healthcare providers that have contracted with the Medicare Advantage plan to provide services at negotiated rates.
Star Rating
Medicare rates Medicare Advantage plans on a scale of 1 to 5 stars based on quality and performance.Higher star ratings generally indicate better quality care.
Special Enrollment Periods (SEPs)
Outside of the AEP,you may qualify for a Special Enrollment Period (SEP) if certain life events occur,such as losing other coverage,moving outside your plan’s service area,or experiencing a change in your health status. SEPs