Medicare Advantage Plans: Coverage, Eligibility, and Other Considerations – Search Site Content

Medicare Advantage Plans: Coverage, Eligibility, and Other Considerations

Medicare Advantage is a part of Medicare sometimes referred to as Medicare Part C. Medicare Parts A and B are known as Original Medicare. Medicare Advantage typically covers the same expenses as Original Medicare, except for hospice care, which falls under Part A.

People opt in to Medicare Advantage Plans as they can offer additional coverage to Parts A and B, including (but not necessarily limited to) dental, vision, and hearing.

How Does Medicare Part C Coverage Work?

Part C plans operate through approved private insurance companies. Medicare Advantage places a cap on yearly out-of-pocket expenses. In other words, insurance covers approved medical costs once this cap limit is reached.

Different types of plans are available under Medicare Advantage. For instance, a Health Maintenance Organization (HMO), a Preferred Provider Organization (PPO), and a Medical Savings Account (MSA) are all plans available through Part C. Private Fee-for-Service (PFFS), Special Needs Plans (SNPs), and HMO Point of Service (HMOPOS) plans are available through Medicare Advantage as well. With so many plans available, it's important to thoroughly research each option. Further information about these plans can be found on the official Medicare government site.

Part C Eligibility and Choosing a Plan

Many people enrolled in Medicare Part A and Part B are generally eligible for a Medicare Advantage Plan, although there are exceptions. One such exception, according to the official government site, is anyone with end-stage kidney disease. Another requirement for potential enrollment in a Part C plan is that interested, eligible individuals must also live in the service area for the plan in which they’re enrolling. For example, someone living in Missouri cannot enroll in a plan only offered to residents of Massachusetts.

When choosing a new plan, remember it’s a personal decision; which option is best will vary based on several factors, including individual or household medical needs. It’s always important to read and compare the details, benefits, restrictions, and costs of various plans, policies, and providers. Check to see which doctors and hospitals are included in a plan’s network. If a preferred doctor or hospital is out of network, note that Medicare Advantage won’t help cover any expenses associated with that practice. It’s still possible to use that doctor or hospital, but the costs will all be out of pocket.

Medications are another important consideration. Many plans help cover prescription drugs, but that doesn’t mean they cover all types of drugs or even all of the costs. Always check to see if a potential plan provides adequate coverage for any necessary prescriptions. Also check to see which plan provides the best cost-sharing advantage.

Further Considerations

Because Part C plans are through approved private insurance companies, note that each company can put certain restrictions on coverage. For example, a Part C plan may have higher co-payments than Original Medicare through certain providers. The amount patients pay and the benefits they receive could be updated each year as well. Sometimes an insurance company may cancel its contract with Medicare, ceasing coverage.

Medicare Advantage and Medigap

Many Medicare Parts A and B recipients have Medigap policies, which are designed to help cover expenses that Original Medicare might not cover. Note that a Medigap policy won’t pay for Medicare Advantage expenses, such a co-payments and deductibles. Also be aware that someone cannot legally sell a Medigap policy to someone already enrolled in a Medicare Advantage Plan (Part C), unless said individual is disenrolling from a Medicare Advantage Plan and returning to Original Medicare.

Disclaimer: This article is neither endorsed nor reviewed by Medicare.


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