Medicare Advantage (Part C) are plans that are offered by private companies to provide extra benefits that are not included in Medicare Part A and B. Most people would prefer the extra benefits because there are many things that Medicare part A and B do not cover. For example parts A and B do not include prescription drugs. So you can afford to go to the doctor and get a prescription but when you go to the pharmacy to get it filled, you run the risk of breaking the bank. Many people barely understand the basics of Medicare, much less Medicare Advantage. Which means it’s the agent’s responsibility to educate the client. In order to educate, the agent must know all of the proper terminology.
Listed below are terms that an agent will need to know and explain to potential clients.
- Appeal- a request for your health insurer or plan to review a decision or a grievance again.
- Allowed Amount- Maximum amount on which payment is based for covered health care services. This may also be called “eligible expense,””payment allowance,” or “negotiated rate.”
- Balance Billing- When a provider bills the client for the difference between the provider’s change and allowed amount.
- Co-Insurance- An amount the client may be required to pay as their share of the cost for health care services or prescriptions after they pay any deductibles.
- Co-payment (Co-pay)- An amount the client may be required to pay as their share of the cost for health care services. Such as doctor visits or prescriptions.
- Deductibles- The amount that the client will have to pay for health services or prescriptions each year, before their insurance beings to pay. The deductible can change each year.
- Estimated Annual Cost- An estimate of the average amount the client might expect to spend each year for health coverage. The client’s out-of-pocket costs are based on actual health coverage used by people with Medicare depending on age and health status. Also, if the client has limited income and resources, the client’s expenses may be lower. The estimate includes, as applicable; plan benefits (coverage), costs for premiums, co-payments, deductibles, and co-insurance. Also cost not covered by the client’s insurance.
- Estimated Annual Drug Cost- An estimate on the average amount you might expect to pay each year for your prescription drug coverage. This estimate includes the following ,as applicable; Monthly Premiums, Annual Deductible, Drug Co-Payments/Co-Insurance, and Drug costs not covered by prescription drug insurance.
- Out-Of-Pocket-Spending Limits- Protects the client by having yearly limits on their out-of-pocket costs for medical and hospital care. If the client reaches the limit on out-of-pocket costs, they continue to receive coverage for hospital and medical services. The insurance company will also pay the full cost for the rest of the year.
- Provider Network- The group of providers who are contracted to provide health care services to plan members.
To find more tips, keep a look out for SMA University which is coming soon!