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Medicare Advantage plans

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All-inclusive Medicare Advantage (Part C) plans combine original Medicare (Parts A and B) coverage with additional benefits that you cannot get from Medicare alone. The majority also offer Part D prescription medication coverage, as well as potential extra benefits like dental, vision, hearing, and fitness. They are frequently offered at no additional premium cost.

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Within predetermined geographic areas known as service areas, Medicare Advantage programs are operational. To join a plan, you must reside inside its service region. By plan and region, a plan’s coverage and fees may change.

What do Medicare Advantage plans cover?

All Medicare Advantage (Part C) plans cover:
 

  • Each and every Medicare Part A (hospital) benefit (hospice coverage may be offered, although in that case, Part A will still provide coverage)*

  • All medical coverage under Medicare Part B

out of pocket costs

The majority of Medicare Advantage Plans include: 

  • Medicines on prescription

Other advantages that Medicare Advantage programs could provide include:

  • Dental cleanings, examinations, and X-rays

  • Examinations, glasses, and corrective lenses for the eyes

  • Hearing evaluations and devices

  • Fitness memberships and wellness initiatives

  • Other advantages include transportation to medical appointments and interactions with virtual providers.


*Hospice treatment will still be covered by Original Medicare Part A for you even if you have a Medicare Advantage plan.

health care providers

Tips to keep in mind when using Medicare Advantage plans
 

  • There will be provider networks in some plans and not in others.

  • Limitations on out-of-pocket expenses can differ by plan.

  • There are several plans available to suit different budgets, with varying plan prices.

What types of Medicare Advantage plans are there?

Coordinated care plans

Coordinated care plans make up the majority of Medicare Advantage (Part C) programs. Plans for coordinated care have a network of service providers. You often spend less out-of-pocket for care if you use the network of providers included in the plan.

Health Maintenance Organization (HMO) plans

A network primary care provider (PCP) is used by HMO plans to assist with care synchronization. HMO insurance policies typically cover only the network of providers.

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Point of Service (POS) plans

The benefits of an HMO plan are available with POS plans, but provider options are more open. If you use the network providers included in the package, costs are typically lower.

Preferred Provider Organization (PPO) plans

Both in- and out-of-network providers are covered by PPO policies. When using an out-of-network provider, these plans cover a portion of the price.

Special Needs Plans (SNPs)

Benefits under special needs plans might be used to meet financial or medical needs. All SNPs cover the cost of prescription medications.

  • Plans for adults with special needs who are dual eligible for Medicaid and Medicare (D-SNPs) (called “dual eligible”)
  • C-SNPs (Chronic Special Needs Plans) for those with severe or incapacitating chronic diseases
  • Plans for institutionalised individuals with special needs (I-SNPs) who reside in skilled nursing facilities
  • Those who reside in an assisted living facility under contract and require care comparable to that provided in a skilled nursing facility may be eligible for Institutional-Equivalent Special Needs Plans (IE-SNPs).

Other types of Medicare Advantage plans


There are two additional Medicare Advantage (Part C) plan types to think about if you prefer greater flexibility in your healthcare providers and payment alternatives.

medicare advantage hmo

Private Fee-for-Service (PFFS) plans

PFFS plans may or may not have a provider network, but they always pay for services from any Medicare-eligible providers. You can also sign up for a different Part D plan if the one you have doesn’t cover prescription drugs under Part D.

Medical Savings Account (MSA) plans

High-deductible health plans and designated savings accounts are combined in MSA plans. Medicare makes deposits of money that can be taken out tax-free to pay for certain medical treatments. Any provider you want can be shown. Part D prescription medication coverage is not offered by MSA plans, but you can sign up for a separate, stand-alone Part D plan.

How Much does a Medicare Advantage Plan cost?

Although each Medicare Advantage (Part C) plan establishes its own unique charges, the costs they all involve are of a similar nature. The chart below lists the different charges that a plan might incur, although the actual prices will depend on the specifics of that plan.

 
 
 PremiumDeductibleCopayCoinsurance
Frequency

Per month

Per year

For the majority of medical services, such doctor visits

With regard to a few items, such durable medical equipment

Details

Plan premiums can differ. You must continue to pay Medicare your Part B premium as well as your Part A premium, if applicable.

Some insurance plans have an annual deductible, while others don’t. Original Medicare Part A and Part B deductibles don’t apply.

For the services and benefits you utilise, many plans impose copays.

Plans choose the conditions and percentages for coinsurance.

The majority of Medicare Advantage (Part C) plans divide the cost of the services you utilise between deductibles, co-insurance, and co-pays. Cost-sharing often applies to all of the covered services under the plan.

To fully understand a Medicare Advantage plan’s costs, you must examine the specifics of each one. Most plans feature network pharmacies and providers who may provide discounted prices to plan participants.

FAQs

What is Medicare Advantage in simple terms?

Medicare Advantage is a private company’s Medicare-approved health and medication coverage option that provides an alternative to Original Medicare. Part A, Part B, and typically Part D are all included in these “bundled” plans. • Typically, you can only use doctors who are part of the network.

medicare advantage plan

What is not covered by Medicare Advantage plans?

Clinical trials, hospice care, and, temporarily, some new benefits resulting from legislation or national coverage rulings are the only benefits that Medicare Advantage Plans do not cover when providing all of your Part A and Part B benefits.

Is there prescription drug coverage under Medicare?

Everyone with Medicare has access to prescription drug coverage. The name of this insurance is “Part D.” 

How does out of pocket costs work on Medicare?

Since 2011, Medicare Advantage plans have been obliged by federal law to provide an out-of-pocket maximum for services covered by Parts A and B. The out-of-pocket maximum for in-network services in 2022 cannot be more than $7,550, and for in-network and out-of-network services combined, it cannot be more than $11,300.

What are the two types of health maintenance organizations?

Prepaid group practise models and medical care foundations (MCF), often known as individual practise associations, are the two basic types of HMOs. The Ross-Loos Medical Group in California, United States, invented the prepaid group practise kind of health care plan in 1929.

Is an ACO a Health Maintenance Organization (HMO), managed care or an insurance company?

No. An ACO is a team of physicians, hospitals, and other healthcare organisations that collaborate to give you better, more streamlined care. In an ACO, medical professionals and facilities engage with you and with one another to ensure that you receive the treatment you require when you are ill and the assistance you require to maintain good health.  An ACO is not a managed care organisation, HMO, or insurance firm. An ACO cannot dictate which medical professionals you should see or alter your Medicare benefits, in contrast to HMOs, managed care, or some insurance plans. You always retain the right to select any hospital or doctor who accepts Medicare at any time, even if your doctor participates in a Medicare ACO.

Is Medicare adding dental and vision care?

In addition to providing the same coverage as Original Medicare, Medicare Advantage (Part C) plans may also cover dental and vision expenses. The majority also offer other perks like gym memberships and hearing health coverage in addition to prescription medicine coverage.

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