Medicare Advantage (MA) Plans are part of the Medicare program and are sometimes called “Part C.” Medicare Advantage Plans provide the same services as Medicare Parts A and B. Most Medicare Advantage plans include prescription drug coverage (Part D) too. Many Medicare Advantage Plans offer extra benefits that Medicare doesn’t cover, such as vision or dental services. Members may have to pay an additional monthly premium for these extra benefits and there may be special rules that members need to follow.
In most Medicare Advantage Plans, members generally get all their Medicare-covered healthcare and prescription drug coverage through the plan.
Medicare pays a set amount of money for a person’s care every month to these private health plans, whether or not the member uses services. The plan is then responsible for all aspects of care from proof of coverage, processing of claims, payment of claims, determination of medical necessity, explanation of benefits, and statements. Medicare Advantage Plans are structured very similar to employer healthcare coverage.
Most people enrolled in a Medicare Advantage Plan must still pay their Part B premium.
Members may also pay an additional monthly premium to the plan. Members also have cost-sharing in Medicare Advantage Plans usually in the form of deductibles, copayments and coinsurance. Cost-sharing in a Medicare Advantage Plan may be different from those in Original Medicare. Because of this, it’s important that people review plan materials carefully for details about copayments and coinsurance for the services they get. Plans set an annual out-of-pocket limit that is approved by Medicare. If a person reaches their out-of-pocket limit then the plan pays at 100% (excluding prescription drug costs).
Medicare Advantage Plans are available to most people with Medicare. To be eligible to join a Medicare Advantage Plan, a person must:
It’s is important to know what a salesman or other representative of a Medicare Advantage Plan can and cannot legally do. Their representatives: