Medicare Advantage (Medicare Part C) coverage and plans
Medicare Advantage (Medicare Part C) is a private insurance alternative to Original Medicare (parts A and B). It also often includes Medicare Part D.
Medicare Advantage is an all-in-one plan that incorporates hospital treatments, physician visits, and, usually, prescription drug coverage.
Some Medicare Advantage plans also cover services that Medicare may not, such as dental, hearing, and vision care.
This article provides details on which services Medicare Advantage covers and how it differs from traditional Medicare.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
What does Medicare Advantage cover?
This article originally appeared on Medical News Today
Medicare Advantage plans must cover the same services as Original Medicare. Original Medicare Part A covers hospital insurance, while Part B covers medical insurance.
Most plans also include Part D, which is prescription drug coverage.
Part A
Medicare Part A covers:
inpatient care in the hospital
skilled nursing facility care
hospice care
home healthcare
Part B
Medicare Part B covers:
doctor’s appointments
outpatient care
durable medical equipment
tests, screenings, and other preventive services
Part D
Many Medicare Advantage plans include Part D, which helps cover the cost of prescription medication.
Some plans, such as Medical Savings Account plans and some Private Fee-for-Service plans, do not include drug coverage. In these cases, a person can purchase separate drug coverage.
Other coverage
Other coverage Medicare Advantage plans may offer include:
hearing
vision
A person may have to receive prior approval for a particular service to make sure that Medicare Advantage will cover it.
Exclusions
In addition to considering what Medicare Advantage plans cover, people need to be aware of what they do not cover. This can help them manage their expectations and avoid any surprising costs if they need treatment later on.
Most Medicare Advantage plans only cover care that a person receives inside the United States and will not cover the treatment they receive in other countries. However, some plans may offer an additional benefit to cover emergency treatment when traveling outside of the United States.
The plans also may not cover nonemergency services at facilities that are “out of network” for a person’s plan.
A person also needs to ensure the plan fully meets their requirements before enrolling.
What Medicare Advantage plans are available?
Thousands of different Medicare Advantage plans are available, and people in every region will have access to different plans. Each plan must coordinate with a network of healthcare providers in a specific area.
Types of Medicare Advantage plans include:
Preferred Provider Organization (PPO)
HMO, PPO, and PFFS may include Part D prescription drug coverage. SNPs always include prescription drug coverage. However, MSA never includes prescription drug coverage.
A person can find out which plans are available in their area by calling 800-MEDICARE (800-633-4227).
Learn about comparing the benefits of Medicare Advantage plans and what they offer.
Benefits of Medicare Advantage plans
Choosing a Medicare Advantage plan is a personal decision. People may base their choice on the upfront cost and the services they would typically need while under coverage.
The following looks at some of the benefits of Medicare Advantage plans.
Premium costs
Medicare Advantage can be more cost-effective than Original Medicare. Many plans even have a $0 premium.
Around 66% of Medicare Advantage enrollees do not pay a prescription drug premium in 2024.
However, a person would still be responsible for paying the Medicare Part B premium.
More expansive coverage
Medicare Advantage plans may cover services that Original Medicare does not, including:
dental care
hearing
vision
fitness programs and gym memberships
prescription drug services
If a person regularly requires these services, the extra coverage can save them money.
Flexibility
A person can research the Medicare Advantage plans available in their area to determine which additional services they may like to receive.
Medicare Advantage has SNPs for people with specific medical conditions, such as diabetes or end stage renal disease (ESRD). This means that a person is more likely to receive coverage for necessary medications and services.
If a person is unsatisfied with the first Medicare Advantage plan they choose, they can switch to a new one during the Medicare Advantage Open Enrollment Period, which is from January 1 to March 31.
They can also choose to return to Original Medicare during this time.
Learn about choosing a Medicare Advantage plan.
Drawbacks of Medicare Advantage
A person can consider some of the potential drawbacks of Medicare Advantage before enrolling in a plan. However, as there are many Medicare Advantage plans available, some of the disadvantages below may not apply to all plans.
Choice
Medicare Advantage plans usually reduce costs by restricting choice. A person must choose from a list of providers or get referrals through their doctor.
In contrast, those with Original Medicare can generally seek care from any provider who accepts Medicare.
Out-of-pocket costs
Out-of-pocket costs may be higher with some Medicare Advantage plans.
However, there is a yearly limit on these costs, which is not the case for Original Medicare. Original Medicare has no out-of-pocket maximum.
Medicare Advantage vs. Original Medicare
As a general rule, Medicare Advantage costs less than Original Medicare. However, Medicare Advantage plans often require a person to seek consultation with doctors who are on the plan’s preferred list of medical professionals. These are known as “in-network” physicians.
Both Original Medicare and Medicare Advantage include Part A and Part B. Some Medicare Advantage plans offer additional coverage, such as Part D prescription drug coverage.
Learn more about how Medicare Advantage and Original Medicare differ.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Summary
Every Medicare Advantage plan must offer the same coverage as Original Medicare Part A (hospital insurance) and Part B (medical insurance).
Most Medicare Advantage plans also often feature Part D prescription drug coverage. Some also provide additional benefits, such as dental, vision, and hearing coverage.
If a person is considering enrolling in a Medicare Advantage plan, they need to find out what plans are available in their area.
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View the original article on Medical News Today
