Medicare Advantage costs and coverage

When choosing a Medicare Advantage Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan, be aware of the different cost-sharing cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. you may face. Costs in MA Plans are often different from in Original Medicare Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. , and may come with additional rules. Consider each plan carefully before enrolling.

• Medicare Part B premium: In an MA Plan, you generally must pay the Part B premium. Plans may also charge you an additional premium. In some cases, the plan may pay part of your Part B premium.
• Deductible Deductible The deductible is the amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year. : MA Plans may charge you a deductible for services, including inpatient inpatient An inpatient is a patient who has been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance). , outpatient outpatient An outpatient is a patient who has not been formally admitted into the hospital as an inpatient. Most outpatient care is covered under Medicare Part B (medical insurance). , and prescription prescription A prescription is an order for a health care service or drug written by a qualified health care professional. drugs. Deductibles will vary by plan.
• Copayment Copayment A copayment, also known as a copay, is a set amount you are required to pay for each medical service you receive (like $35 for a doctor’s visit). : MA Plans usually charge a copayment (copay) for doctor’s visits, instead of the 20% coinsurance coinsurance The coinsurance is the portion of the cost of care you are required to pay after your health insurance pays. Usually, it is a percentage of the approved amount or negotiated amount. In Original Medicare, the coinsurance is usually 20% of Medicare’s assignment. you pay under Original Medicare. Keep in mind that MA Plans cannot charge higher copays than Original Medicare for certain care, including chemotherapy, dialysis dialysis Dialysis is the treatment used to artificially cleanse your blood of toxins when your kidneys no longer work. , and skilled nursing facility (SNF) skilled nursing facility (SNF) Skilled nursing facilities (SNFs) are Medicare-approved facilities that provide short-term post-hospital extended care services. care.
• Maximum out-of-pocket (MOOP) limit: All plans must include a maximum out-of-pocket limit out-of-pocket limit See Maximum Out-of-Pocket (MOOP). . This means the amount you pay out of pocket is capped for the year, which protects you from excessive costs if you need a lot of care or expensive services. These limits are typically high, and they include copays and deductibles.

In addition to the above, remember that MA Plans have different coverage rules.

• Many plans cover services only if you receive them from doctors, hospitals, and pharmacies that are in the plan’s network network A network is a group of doctors, hospitals, and pharmacies that contract with a Medicare Advantage Plan to provide health care services. Generally, plan members will have the lowest costs when using providers and facilities in the plan’s network. Networks may be made up of both preferred and non-preferred providers. . Before you join an MA 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. Keep in mind that doctors and hospitals may leave the plan at any time, but you can only leave an MA Plan during an enrollment period if you want to avoid incurring a penalty.
• Though MA Plans must cover the same 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, a plan may require your provider to ask the plan’s permission before giving you certain services, or require more formal referrals to see specialists or prior authorization prior authorization Prior authorization, also known as pre-authorization or pre-approval, is a restriction placed on coverage by Part D plans and Medicare Advantage Plans. If a service or drug requires prior authorization, you must first get approval from the plan for it to be covered. If you fail to get prior authorization before you get the service or drug, your plan generally will not cover it. for certain services.

Remember: you cannot buy a Medigap Medigap A Medigap is a supplemental health insurance policy that is sold by private insurance companies and works only with Original Medicare. Medigaps pay part or all of certain remaining costs after Original Medicare pays first. Depending on where you live and when you became eligible for Medicare, you have up to 10 different Medigap policies to choose from, each with a different set of standardized benefits.  policy to supplement an MA Plan and cover cost-sharing. Medigap policies only work with Original Medicare.