What is Covered Under Medicare Advantage Plans?
By law, all Medicare Advantage (MA) plans must provide the same basic healthcare services for inpatient care and outpatient care as Medicare Part A (hospital coverage) and Medicare Part B (medical coverage), commonly referred to as Original Medicare. The similarities end there, so it’s important to learn what MA plans cover and how to compare plans to find the best for your needs.
In this article, we’ll answer the following popular questions about what Medicare Advantage covers, and many more:
By law, Medicare Advantage plans must cover all of the services that Original Medicare (Part A and Part B) covers except hospice care. Medicare covers hospice directly. Most Medicare Advantage plans also offer extra benefits, including prescription drug coverage (Part D), and routine dental care, eyeglasses, and wellness programs, like SilverSneakers. For a complete breakdown, read: What Does Medicare Advantage Cover?
Most Medicare Advantage Plans offer coverage for things that Original Medicare does not cover, like vision, hearing, dental, and wellness programs. However, most plans will not cover the range of holistic (alternative) medicine. There are some acceptions, such as acupuncture for chronic back pain, and other therapies and medicines that Original Medicare does not cover. Plus, plans generally do not cover elective surgeries unless required for medically necessary reasons. For a complete list of what's not covered by Medicare Advantage, read: What Does Medicare Advantage Cover?
The primary advantage is the monthly premium, which is generally lower than Medigap plans. The top disadvantages are that you must use provider networks and the copays can nickel and dime you to death. To discover all of the pros and cons of Medicare Advantage, read: What are the Advantages and Disadvantages of Medicare Advantage Plans?
There are 7 common reasons that some Medicare beneficiaries, and many healthcare professionals, feel that Medicare Advantage plans are bad. They include higher costs, less freedom to choose healthcare providers, doctor referrals for most services, high maximum out-of-pocket limits, annual changes to health plan benefits, costs, and providers. Read Why Medicare Advantage Plans are Bad: 7 Top Complaints to discover all of the dirty secrets about Medicare Advantage plans.
Even though the Centers for Medicare & Medicaid Services (CMS) mandates that all insurers offer the same basic coverage (i.e., hospital insurance, medical insurance, hospice care, etc.) in their Part C plans, they do not require plans to cover medical care benefit in the same way. Specifically, plans are free to set their own shared-cost rates (i.e., copayments, coinsurance, and deductibles), and they are allowed to place limitations on services (e.g., referrals).
However, unlike the Original Medicare and Medigap (supplemental insurance) system, Medicare Advantage plans may add additional benefits, such as Medicare prescription drug coverage, and routine dental, vision, and hearing care.
In addition to the extra benefits just mentioned, Medicare Advantage plans may offer these coverage options:
- Safety devices for the home that reduce the risk of injury.
- Transportation to health-related services, such as the doctor’s office or pharmacy
- Emergency care coverage outside the country
- Over-the-counter medications
- Adult day-care services
Not all plans offer additional benefits. That’s why it is important to carefully compare Medicare Advantage plans before joining.
What is Not Covered by Medicare Advantage plans?
If you are wondering, “Does Medicare Advantage cover everything?”, it doesn’t.
Most Medicare Advantage Plans offer coverage for things that Original Medicare does not cover, like vision, hearing, dental, and wellness programs (like SilverSneakers gym memberships). That said, Part C plans have their limitations.
Most plans will not cover the range of holistic (alternative) medicine. There are some acceptions, such as acupuncture for chronic back pain, and other therapies and medicines that Original Medicare does not cover.
Also, Medicare Advantage plans generally do not cover elective surgeries, such as plastic surgery, unless it is required for medically necessary reasons. And, plans put service limitations on additional benefits, such as dental care and procedure. In other words, the additional benefits are not unlimited. Learn more about how Medicare Advantage plans work here.
What is the Difference Between Medicare Advantage and Medicare Part C?
Medicare organizes its benefits in parts. Medicare Part C is the Medicare Advantage program. They are one and the same. There is no difference between Medicare Part C plans and Medicare Advantage plans.
It’s easy to confuse the parts and plans terminology. Just remember this. When you see the word plan, it is a health insurance offering from a private insurance company. When you see the word part, it is a Medicare benefit.
For example, the terminology Plan B refers to a specific Medicare supplement plan. It is not the same as Medicare Part B, which is medical coverage for people enrolled in Original Medicare.
Who Can Join a Medicare Advantage Plan?
In most cases, if you have both Medicare Part A and Medicare Part B you can join a plan. However, if you have end-stage renal disease (ESRD), a plan is not required to let you join.
Also, be aware that when you join a plan you will automatically be dropped from your Part A and Part B benefits. You cannot have both. However, you can go back to Original Medicare and your Part A and B benefits will be restored.
Types of Medicare Advantage Plans
There are a few different types of Medicare Advantage plans, including HMOs (Health Maintenance Organization plans), PPOs (Preferred Provider Organization plans), PFFS (Private Fee For Service plans), and Medical Savings Account (MSA) plans.
How Do Medicare Part C Plans Work?
We’ve created an entire article to explain how Medicare Advantage plans work. It’s worth mentioning that what each individual Medicare Advantage plan covers does not change how CMS administers private health plans. The rules remain the same. This includes Medicare drug coverage, too. If a plan includes prescription benefits, it must be an authorized Medicare Part D plan.
What are the Benefits of Medicare Advantage Plans?
Original Medicare covers your major medical costs, but it does not cover minor medical, including a prescription drug plan, routine dental, vision, hearing, gym memberships, to name just a few. This is the primary benefit of Medicare Advantage. Medicare Advantage plans cover additional benefits that Original Medicare coverage can’t.
There are other benefits to these private insurance plans, too. For example, Special Needs Plans (SNPs) help people with certain chronic health conditions. There are also SNPs for people who qualify for Medicaid. In most cases, the copays and other cost-sharing requirements with these plans are exceptionally low.
Along with the benefits come a few disadvantages, as well. For instance, nearly all plans use provider networks and require you to see your primary care doctor for referrals to see a specialist. And, Medicare Advantage plans don’t work outside of their service area. But, don’t worry, if you have an emergency away from home, Medicare Advantage covers it (in the USA and its territories only).
NOTE: If you join a Part C plan you must continue to pay your Medicare Part B monthly premium as well as the additional premium charged by the MA plan. If the plan has a zero-dollar premium, that means your Part B premium covered the cost in full and there’s no additional monthly cost.
Who Needs Medigap Insurance?
It’s important to mention that Medicare Advantage isn’t a great option for everyone. Here are some circumstances when Medigap (aka, Medicare supplement insurance) is a better option:
- Rural areas — Medicare Advantage plans may be limited or not available at all in rural counties. When they are, it’s likely to be a PFFS plan or a severely limited HMO plan.
- Chronic health conditions — If you have one or more chronic health conditions that require frequent health care, and you don’t have retiree benefits that help with MA plan copays on covered services, and you don’t qualify for Medicaid, a Medicare Advantage plan could get very expensive.
- Health care providers — If your doctor or specialist is not part of a plan’s network, and you can’t or do not want to find a new physician, a Medicare Advantage plan is not a good option.
It all comes down to choice vs. additional benefits and availability.
NOTE: You cannot have both a Medicare supplement (Medigap) and be enrolled in a Medicare Advantage plan. The two types of health insurance are not compatible.
How to Apply for Medicare Part C
Unlike Original Medicare, there is are specific enrollment periods for MA plans. If you are getting your Medicare benefits for the first time you have an Individual Enrollment Period (IEP) that allows you to join a plan. Outside of your IEP, the period when you can join, change, or return to Original Medicare is during the Fall open enrollment period, which begins 15 October and ends 7 December.
Citations & References:
- Find a Medicare plan
- Medicare Advantage Plans | Medicare
- Joining a health or drug plan | Medicare
- 2020 Medicare Parts A & B Premiums and Deductibles | CMS
- Trump Administration Announces Historically Low Premiums and New Insulin Bene…
- Home – Centers for Medicare & Medicaid Services | CMS
- Medicare Advantage | KFF
- A Dozen Facts About Medicare Advantage in 2020 | KFF
- State Category | Medicare | KFF
- Medicare Benefits | SSA
- The United States Social Security Administration
This article was written by David Bynon, and was last updated on .