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Medicare Advantage Basics


A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care). These rules can change each year.

  • You can only join a plan at certain times during the year. In most cases, you’re enrolled in a plan for a year.
  • As with Original Medicare, you still have Medicare rights and protections, including the right to appeal.
  • Check with the plan before you get a service to find out whether they will cover the service and what your costs may be.
  • You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan.
  • You can join a Medicare Advantage Plan even if you have a pre-existing condition, except for End-Stage Renal Disease.
  • If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan.
  • If the plan decides to stop participating in Medicare, you‘ll have to join another Medicare health plan or return to Original Medicare.

Below is a basic outline of how a Medicare Advantage Plan would offer benefits. Because these plans DO NOT supplement Medicare (rather they replace Original Medicare and provide the A and B benefits for you) you will have expenses to pay should you require a hospital stay or surgery. That is the trade off for not paying an additional premium for supplemental coverage.

Medicare Advantage Chart

 

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