By law, Medicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). must provide the same basic healthcare services for Inpatient care refers to care provided in a hospital or other inpatient facility. Inpatients are admitted and stay at least one night depending on their condition. and Outpatient Care is medical care that does not require an overnight stay at the hospital. Medicare Part B provides coverage for Outpatient Care. as Original Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.. The similarities end there, so it’s important to learn what private health plans cover and how to compare plans to find the best for your needs.
- Medicare Advantage plans must cover all of the benefits in Medicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Medicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services., however, they are not required to cover benefits in the same way.
- Medicare Advantage plans may include additional benefits not included in Part A and Part B.
- Most plans include a Medicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... plan for prescription drug coverage.
- Many plans include dental, vision, and hearing benefits, which may or may not include an additional monthly premium.
- Many plans cover telehealth services.
- A limited number of plans offer non-emergency transportation services and at-home care services.
- Plans may require you to get Prior authorization is a process used by health plans to control healthcare costs. Most HMO plans and some PPO plans require authorization before receiving certain treatments, medical services, or prescription drugs. before they will cover a service.
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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 is a special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. 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., A copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service., Coinsurance is a percentage of the total you are required to pay for a medical service. , and A deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.), 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.
Do you know the answers to these popular questions about Medicare Advantage plans?
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.
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.
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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 Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. 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), also known as kidney failure, is a condition that causes you to need dialysis or a kidney transplant. People with ESRD are eligible for Medicare coverage regardless of age. (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.
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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 is a public health insurance program that provides health care coverage to low-income families and individuals in the United States.. 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 Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. (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.
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Citations & References:
- Find a Medicare plan
- Medicare Advantage Plans | Medicare
- Joining a health or drug plan | Medicare
- 2020 Medicare Parts A & B A premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of 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