Medicare Advantage

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.


How do Medicare Advantage Plans work?

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. 


What are the Costs of Medicare Advantage Plans?

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).


Who Can Join?

Medicare Advantage Plans are available to most people with Medicare. To be eligible to join a Medicare Advantage Plan, a person must:

  • Live in the plan’s geographic service area or continuation area,
  • Be enrolled in Medicare Part A and Part B,
  • Agree to provide the necessary information to the plan,
  • Agree to follow the plan’s rules, and
  • Belong to only one Medicare Advantage plan at a time.

Marketing Guidelines for Medicare Advantage Plans

It’s is important to know what a salesman or other representative of a Medicare Advantage Plan can and cannot legally do. Their representatives:

  • May send information
  • May conduct outbound telemarketing activities
  • Must use marketing materials that have been reviewed by the Centers for Medicare & Medicaid Services
  • Must comply with the “Do not call registry”
  • Must provide information in a professional manner
  • Must use state-licensed, certified or registered individuals to market plans

Representatives of Medicare Advantage Plans:

  • May not solicit Medicare beneficiaries door-to-door (unless invited)
  • May not send unsolicited email
  • May not enroll people by phone (unless the person calls them)
  • May not offer cash payment as an inducement to enroll
  • May not misrepresent or use high-pressure sales tactics

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