What is a Medicare Advantage plan?

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While the majority of people with Medicare get their health coverage from Original Medicare, some people choose to get their benefits from a Medicare Advantage plan, sometimes called a Medicare private health plan.

Medicare Advantage plans contract with Medicare and are paid a fixed amount to provide Medicare benefits. They are generally managed care plans. The most common types are Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Private Fee-For-Service (PFFS) plans.

You may also see Medicare Advantage plans called Special Needs Plans (SNP), Provider Sponsored Organizations (PSO) and Medicare Medical Savings Accounts (MSAs).

You still have Medicare if you join a Medicare Advantage plan. In most cases, you must still pay your Part B monthly premium (and your Part A premium, if you have one). The plan must provide all Part A and Part B services but can do so with different rules, costs and restrictions that can affect how and when you can get care.

All Medicare Advantage plans must include a limit on your out-of-pocket expenses for Part A and B services. These limits tend to be high. Plans can’t charge you more than Original Medicare for certain services, like chemotherapy and dialysis, but they can charge you more than Original Medicare for others, like home health and inpatient hospital services. Medicare Advantage can also provide additional benefits that Original Medicare does not cover, such as routine vision or dental care.  

Different types of plans have different rules for how and where you can get coverage. However, even plans of the same type may have slightly different rules so you should always check with a plan directly to find out how coverage works.

Medicare Advantage plans often charge a premium in addition to the Medicare Part B premium. They also generally charge a fixed amount called a copayment whenever you receive a service.

You can join any Medicare Advantage plan if:

  • You have Medicare Parts A and B; and
  • You live in the plan's service area; and
  • You do not have End-Stage Renal Disease (ESRD).
    • If you have ESRD that requires dialysis or a kidney transplant, you can enroll in an MA plan if you join a Special Needs Plan that specifically accepts people with ESRD or if other special circumstances apply.

If you want Medicare coverage through a Medicare Advantage and also want drug coverage (Part D), you must generally choose a plan that has this drug coverage as part of its benefits package. If you join an MSA, a PFFS without drug coverage, or a Cost Plan, you can join a stand-alone Part D drug plan. 

If you have health coverage from your union or current or former employer when you become eligible for Medicare, your coverage may automatically convert into a Medicare Advantage plan. You have the choice to stay with this plan, choose Original Medicare, or switch to another Medicare Advantage plan.

Be aware that if you switch to Original Medicare or another Medicare Advantage plan instead, the employer or union could terminate or reduce your health benefits, the health benefits of your dependents, and any other benefits you get from your company. Talk to your plan before switching to find out how your health benefits and other benefits will be affected.


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How much does it cost each month for me to have Original Medicare?

What is not covered by Medicare?

Joining a Medicare Advantage plan

What is a Medicare HMO?

Medicare Preferred Provider Organizations (PPOs)

Medicare Private Fee-for-Service (PFFS) plans

Special Needs Plans (SNPs)

Medicare Medical Savings Account (MSA) plans

How do I enroll in the Medicare prescription drug benefit (Part D)?

 
LINKS
Medicare.gov

American Kidney Fund

National Forum of End-Stage Renal Disease (ESRD) Networks

National Institute of Diabetes and Kidney Diseases (NIDDK)

State Health Insurance Assistance Program (SHIP) Directory

 
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