MEDICARE ADVANTAGE

Medicare Advantage is an “all in one” alternative to Original Medicare.

Medicare Advantage Plans are a type of Medicare health plan offered by a private company that contracts with Medicare to provide all your Part A and Part B benefits. Most Medicare Advantage Plans also offer prescription drug coverage. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan. Your Medicare services aren’t paid for by Original Medicare.

Medicare Advantage Plans must cover all of the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. In all types of Medicare Advantage Plans, you're always covered for emergency and urgently needed care.

The following are common types of Medicare Advantage Plans:

  • Health Maintenance Organization (HMO) Plans  

  • Preferred Provider Organization (PPO) Plans

  • Private Fee-for-Service (PFFS) Plans

  • Special Needs Plans (SNPs)

 

Plans can choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered, check with your Provider before you get the service.

How do Medicare Advantage Plans work?

Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare. 

If you join a Medicare Advantage Plan, you still have Medicare.  These "bundled" plans include  Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare prescription drug (Part D).

Covered Services in Medicare Advantage Plans

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:

  • Whether you need a referral to see a specialist

  • If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care

These rules can change each year.

Rules for Medicare Advantage Plans

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:

  • Whether you need a referral to see a specialist

  • If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care

These rules can change each year.

Costs for Medicare Advantage Plans

What you pay in a Medicare Advantage Plan depends on several factors. 

Your out-of-pocket costs in a Medicare Advantage Plan (Part C) depend on:

  • Whether the plan charges a monthly premium .  Some plans have no premium.

  • Whether the plan pays any of your monthly Medicare Part B (Medical Insurance) premium.  Some plans pay all or part of your Part B premium.

  • Whether the plan has a yearly deductible or any additional deductibles.

  • How much you pay for each visit or service ( copayment or coinsurance ). For example, the plan may charge a copayment, like $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare .

  • The type of health care services you need and how often you get them.

  • Whether you go to a doctor or supplier who accepts assignment if:

    • You're in a PPO, PFFS, or MSA plan.

    • You go out-of-network .

  • Whether you follow the plan's rules, like using network providers.

  • Whether you need extra benefits and if the plan charges for it.

  • The plan's yearly limit on your out-of-pocket costs for all medical services.

  • Whether you have Medicaid or get help from your state.

Drug coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include prescription drug coverage (Part D). You can join a separate Medicare Prescription Drug Plan with certain types of plans that:

  • Can’t offer drug coverage (like Medicare Medical Savings Account plans)

  • Choose not to offer drug coverage (like some Private Fee-for-Service plans)

 

You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:  

  • You’re in a Medicare Advantage HMO or PPO.  

  • You join a separate Medicare Prescription Drug Plan.​

How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans

Medigap policies can't work with Medicare Advantage Plans.

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