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Back To Medicare Advantage PlansBlog 8 of 9Prev   Next


What is the Difference Between a Medicare Advantage Plan and a Medicare Part D Plan?

Publish On 2007-08-17 , 7:23 PM

Question:  What is the difference between a Medicare Part D Prescription Drug Plan (PDP) and a Medicare Advantage Plan? Does either plan cover the donut hole?

Brief Answer:
Medicare Part D plans address only prescription drug coverage.

Medicare Advantage plans come in two general groups:
(1) Medicare Advantage plans with prescription drug coverage (MA-PD) and
(2) Medicare Advantage plans without prescription drug coverage (MA).

Medicare Advantage plans are a combination of your Medicare A (hospitalization) and Medicare B (Doctor visits) - plus usually some additional benefits like optical or dental.  If you have a MA-PD, then your Medicare Advantage plan also covers Medicare Part D (along with your Medicare A and B).   A Medicare Advantage plan is also known as Medicare Part C.

You must have either Medicare Part A and/or Medicare Part B to be eligible for a Medicare Part D prescription drug plan.  Medicare Part D monthly premiums are in addition to your Medicare Part A (if any) and/or Part B premiums.

You must have both Medicare A and B to get into a Medicare Advantage plan.   Your Medicare Advantage plan monthly premiums (if any) are in addition to your Medicare A (if required) and Medicare B premiums.

Like the Medicare Part D prescription drug plans, the Medicare Advantage plans are administered by private insurance carrier and compensated partially by the Federal Government.   As noted, some Medicare Advantage plans do not charge much of a premium (some plans charge no additional premium) and other Medicare Advantage plans offer additional prescription drug coverage at a reduced or even no additional cost (and are termed MA-PD or Medicare Advantage plans with a prescription drug benefit).


The Different Structures of a Medicare Advantage Plan
Medicare Advantage plans can be further defined by how the private insurance carriers choose to implement the Medicare Part A and Part B coverage.  Some Medicare Advantage plans are PPOs (Preferred Provider Organizations) - other MAs are organized as HMOs (Health Management Organizations) - and still other MAs are set up as PFFSs (Private Fee for Service Organizations).

A number of key differences exist between the organization of a PPO, HMO, and PFFS.  All three have distinct advantages and disadvantages.  When considering a MA, a Medicare beneficiary should be sure to learn about these differences and how the choice of a particular MA plan may affect  their health care.


The Private Market and Medicare Advantage Plans
From a very general perspective, Medicare Part D plans and Medicare Advantage plans were both introduced to take advantage of the competitive forces existing in a private market to help control the medical expenses.  As noted in a recent  (August 13, 2007) CMS Press Release:

"[M]any beneficiaries have access to a Medicare Advantage plan with lower prescription drug premiums. It will be important for beneficiaries to compare their coverage options for 2008 based on overall cost, coverage, and convenience in order to select the plan that best meets their needs.

MA-PD premiums continue to be lower than PDP premiums. On average, in 2007, the MA-PD premiums prior to rebates are about $7 lower than those for PDPs. In 2008, they will average $11 lower. The lower MA-PD bids and premiums reflect the effects of aggressive competition as well as lower costs resulting from better care coordination and drug benefit management techniques. In practice, many MA-PD plans also apply a portion of their rebates from Parts A and B to reduce their Part D premiums, in many cases to zero." (CMS Press Release 08/13/2007)  The entire CMS Press Release can be found as part of our Blog here.


Marketing Compliance and the Medicare Advantage Plan
On another note, as some readers have noticed, PFFS Medicare Advantage plans have been in the press during the last few months due to unethical marketing activities.  You can read more about that here:
Plans Suspend PFFS Marketing;Plans adopt strict guidelines in response to deceptive marketing practices.


Doughnut Hole Coverage in 2008?
Very few 2007 Medicare Part D plans or Medicare Advantage plans offer comprehensive or complete Doughnut Hole coverage
(both Brand Name and Generics).  However, in 2007 more Part D plans started offering some form of generic medication coverage in the Doughnut Hole.

It seems unlikely that  many other insurance carriers will offer complete Doughnut Hole coverage in 2008, but we will not know for certain until CMS (Centers for Medicare and Medicaid Services) releases the 2008 plans in mid- to late-September.  (Read More Here)



 
Comment

1. Leslie Norwalk, CMS Deputy Administrator, summed up  Medicare Advantage plans in his testimony before the Senate Subcommittee on Federal Financial Management (September 2005):

"The Medicare Advantage (MA) program provides beneficiaries with the choice to have all of their care coordinated through a single entity. The majority of individuals covered in the private market today receive their care through a preferred provider organization (PPO). The PPO screens providers and facilities, encourages them to provide clinically sound care, and may provide patients with coordination of their care so that the various physicians and facilities involved with them better communicate concerning the patient's needs. Furthermore, PPOs provide patients with the flexibility to go outside of established networks if they so choose. Most Medicare beneficiaries have not had access to this model of care though it prevails in the private market today. Instead, during a single episode of care their claims may be processed by several different entities, and they will have to deal with a range of caregivers that may or may not have avenues for coordinating care, and payment systems that do not always provide incentives to encourage the highest quality of care. This has changed with the implementation of the MA program.

The existing MA coordinated care plans and the new local and regional MA PPOs offer all of these services to people with Medicare. People with Medicare who receive their care through an MA plan have the added bonus of lower out of pocket costs than do those in traditional fee-for-service Medicare. For a typical person with Medicare who receives their care through an MA plan, the savings average $100 per month over what they would spend in regular fee-for service, and savings are higher for those in poor health. To the extent that a MA plan's bid for providing Medicare benefits is below the established benchmark amount, which is generally based on prevailing fee-for-service costs in the area, it receives payments in addition to its bid to fund improved benefits, reduced cost-sharing or reduced plan premiums. This can mean savings for people with Medicare who enroll in an MA plan, or expanded services, such as coverage for eyeglasses, hearing aids and other items not currently covered under traditional Medicare."


Statement by Leslie Norwalk
Deputy Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
on
Cost and Medicare Part D
before
Senate Subcommittee on Federal Financial Management
Government Information and International Security of the
Committee on Homeland Security and Government Affairs
Thursday, September 22, 2005
- by Online Editor, 2007-07-19, 9:27 AM



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