Medicare Advantage plan coverage

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Medicare Advantage plan (private health plan) coverage:

  • Before you join a Medicare Advantage plan, make sure you understand the plan’s costs, rules and restrictions. Medicare Advantage plans can be less costly than Original Medicare if you do not need a lot of care, but you have less freedom to decide when you get care, what care you get, and which doctors you use.

  • Medicare Advantage plans have a limit on your out-of-pocket costs (deductibles and co-pays).  These limits may be high, but they will protect you from excessive out of pocket costs if you need a lot of care or expensive treatment. 

  • Medicare Advantage plans cannot charge higher copayments than Original Medicare for certain care. This includes chemotherapy, dialysis and durable medical equipment. However, they can charge you more for other services, including home health, skilled nursing facility and inpatient hospital services.

  • Many plans cover services only if you receive them from doctors, hospitals and pharmacies that are in the plan’s network. Before you join a Medicare Advantage plan, make sure your doctors (or other providers you may want to use in the future) are in the network and that they are accepting new patients from the plan.

  • Even though Medicare Advantage plans must cover all health services that Original Medicare covers, they may ask you to pay more for certain services or require that you take certain steps before they will pay for your care. For example they can ask you to get official permission from the plan before receiving certain services; this is called prior authorization.

  • Medicare Advantage plans can put other restrictions on the care that you receive, such as requiring that you get a referral from your primary care doctor to see a specialist. They can also require that your doctor ask the plan’s permission before giving you certain services or drugs.

  • Medicare Advantage plans may also close, requiring you to find a new Medicare Advantage plan or return to Original Medicare.

  • Keep in mind that doctors and hospitals may leave the plan at any time, but you can only leave a Medicare Advantage plan at certain times of the year.

  • Finally, remember that you cannot buy a Medigap policy to supplement a Medicare Advantage plan. Medigap policies work only with Original Medicare.

Related Questions
Can my state give me more rights and protections than federal law regarding Medigap plan enrollment?

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Types of Medicare Advantage plans

 
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State Health Insurance Assistance Program (SHIP) Directory

 
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