Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plans must work to maintain access to health care services and prescription drugs during emergencies for plan members living in affected areas. Plans must meet certain requirements following the declaration of a disaster, emergency, or public health emergency.
In these cases, Medicare Advantage Plans must:
- Allow you to receive health care services at out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. doctor’s offices, hospitals, and other facilities
- Waive referral Referrals are authorizations that Medicare Advantage Plans usually require for services not provided by your primary care provider (PCP). For example, Health Maintenance Organizations (HMOs) generally require you to get a referral from your PCP in order to see a specialist or get an eye exam. requirements
- Charge in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. cost-sharing amounts for services received out of network
- Suspend rules requiring you tell plans before you get certain kinds of care or prescription drugs, if failing to contact the plan ahead of time could raise your costs or limit your access to care
In these cases, Part D plans must:
- Cover
formulary
The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket.
Part D drugs filled at out-of network pharmacies
- Part D plans must do this when you cannot be expected to get covered Part D drugs at an in-network pharmacy
- Remove restrictions that stop you from getting refills too soon
- Cover the maximum supply of your refill if you request it
After the disaster, emergency, or public health emergency ends, plans can stop following these requirements. The government will typically indicate when the emergency has ended.