Understanding Medicare Managed Care Plans

Medicare managed plans are an alternative to original Medicare (parts A and B). Sometimes referred to as Medicare Part C or Medicare Advantage, Medicare managed care plans are offered by private companies.

These companies have a contract with Medicare and need to follow set rules and regulations. For example, plans must cover all the same services as original Medicare.

You can choose from among a few kinds of Medicare managed care plans. The plan types are similar to what you might’ve had in the past from your employer or the Health Insurance Marketplace.

Types of Medicare managed care plans include:

• Health Maintenance Organization (HMO). An HMO is a very common health plan type that works with a network. You’ll need to see providers who are part of your plan’s network to get your care covered. An exception is made for emergency care; this will be covered even if you go to an out-of-network provider.
• Preferred Provider Organization (PPO). A PPO also works with a network. However, unlike with an HMO, you can see providers who aren’t part of your network. Your out-of-pocket cost to see those providers will be higher, though, than if you see an in-network provider.
• Health Maintenance Organization Point of Service (HMO-POS). An HMO-POS plan works with a network, like all HMO plans. The difference is that an HMO-POS plan allows you to get certain services from out-of-network providers — but you’ll likely pay a higher cost for these services than if you see an in-network provider.
• Private Fee-for-Service (PFFS). A PFFS is a less common type of managed care plan. PFFS plans don’t have networks. Instead, for a present price, you can see any doctor who contracts with Medicare. However, not all providers accept PFFS plans.
• Special Needs Plan (SNP). An SNP is a managed care plan designed with a specific population in mind. SNPs offer additional coverage beyond a standard plan. There are SNPs for people with limited incomes, who are managing certain conditions, or who live in long-term care facilities.

There are a few changes to Medicare managed care plans in 2021.

One of the biggest changes is that people who are eligible for Medicare through a diagnosis of end stage renal disease (ESRD) are now able to purchase a managed care plan. Previously, they could enroll in only original Medicare and Medicare Part D.

Another change is the addition of two special enrollment periods. This is a time outside of the yearly enrollment windows when you can change your Medicare plan. It generally includes major life changes, like moving or retirement.

Starting in 2021, you’ll also qualify for a special enrollment period if:

• you live in a “disaster area,” as declared by the Federal Emergency Management Agency (FEMA) — for example, if your area has been struck by a hurricane or other natural disaster
• your current health plan is a “poor performer,” according to Medicare
• tour current health plan is having financial trouble and has been placed in receivership
• your current health plan has been sanctioned by Medicare

Other changes include a revised managed care enrollment form and the ability to sign your enrollment documents with an e-signature.

Managed care plans take the place of original Medicare. Original Medicare includes Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

When you have a managed care plan, all your costs will be included. You don’t need to know whether Part A or Part B cover a service because your managed care plan will cover all the same things.

Managed care plans are also referred to as Medicare Part C (Medicare Advantage) plans. These plans cover everything original Medicare does, and they often cover additional services as well. For example, original Medicare doesn’t cover routine dental care, but many managed care plans do.

Managed care plans sometimes include coverage for Medicare Part D, which is prescription drug coverage. Managed care plans often include this coverage with your plan. This means all your coverage will be under one plan. A managed care plan that includes Part D coverage is known as a Medicare Advantage Prescription Drug (MAPD) plan.

Is Medigap managed care?

A Medigap plan, also known as Medicare supplement insurance, is optional coverage you can add to original Medicare to help cover out-of-pocket costs. Medigap plans can help you pay for things like:

• coinsurance costs
• copayments
• deductibles

These aren’t a type of managed care plan.

The cost of a Medicare managed care plan will depend on which plan you select, and the plans available to you will depend on where you live. Managed care plans are often specific to a state, region, or even city.

You can find plans in a variety of price ranges. For example, plans in St. Louis, Missouri, range from $0 to $90 per month.

The cost for a Medicare managed care plan is in addition to your cost for original Medicare. Most people receive Part A without paying a premium, but the standard Part B premium in 2021 is $148.50.

The cost of your managed care plan will be on top of that $148.50. So, if you select a plan with a $0 premium, you’d continue to pay $148.50 per month. However, if you selected a $50 plan, you’d pay a total of $198.50 per month.

You’ll need to be enrolled in both Medicare Part A and Part B to be eligible for a managed care plan. You can become eligible for parts A and B in a few ways:

• by turning age 65
• by having a disability and receiving 2 years of Social Security Disability Insurance (SSDI)
• by having a diagnosis of ESRD or amyotrophic lateral sclerosis (ALS)

Once you’re enrolled in Medicare parts A and B, you’ll be eligible for a managed care plan.

You can search for and enroll in plans in your area using Medicare’s plan finder tool.

It allows you to input your ZIP code and other personal information, like the prescriptions you take. It’ll then match you with plans in your area. You can sort plans by their cost to you, then look at the details for each available plan.

Once you’ve selected a plan, you can click “enroll.” The website will walk you through enrolling in the plan. You’ll need to have your red-and-white Medicare card on hand to provide information like your Medicare number and your Medicare parts A and B start date.

You can also enroll in a managed care plan directly with providers in your area. You can use their websites or call them to enroll over the phone. You can search online for insurance companies that offer Medicare managed care plans in your area.

Is a Medicare managed care plan right for you?

Questions to consider:

• Do you need any of the extra coverage offered by plans in your area?
• Are there plans in your area that fit your budget?
• Is your current doctor part of the network of the plans you’re considering?
• How often do you use your Medicare coverage?

• Medicare managed care plans take the place of original Medicare. You can find managed care plans in HMO, PPO, HMO-POS, PFFS, and SNP formats.
• Plans often include additional coverage for services that original Medicare doesn’t cover.
• Plans are available at a range of price points. The plans available to you will depend on your location.

Medicare plan options and costs are subject to change each year.