Medicare Advantage costs and coverage

​

New benefits that come from laws or Medicare policy decisions along with all of you Part A and Part B benefits are generally provided for in Medicare Advantage Plans.  Medicare Advantage plans generally cover most emergency and urgent care, both physical and mental, and the necessary medical services found in Original Medicare plans.

​

Clinical trials and hospice service benefits are usually excluded in Medicare Advantage plans.  Generally, Original Medicare will help cover your costs for hospice care along with some costs for clinical research studies if you’re in an Medicare Advantage Plan. 

​

A Medicare Advantage Plan has the option to not cover the costs of services that are not medically necessary under Medicare.  If you are uncertain regarding service coverage, check with your provider beforehand.

​

Part A, Part B and usually Part D coverage is normally bundled into a Medicare Advantage plan.  Extra benefits that Original Medicare does not cover such as vision, hearing, and dental coverage may be found in some Medicare Advantage Plans.  Private companies that offer Medicare Advantage Plans must be Medicare-approved.  Rules for how you get services such as needing referrals to see a specialist can be different in each plan.  Monthly premiums and costs for services can vary depending on which plan you join.

​

Generally, emergency and urgent care and almost all medically necessary services Original Medicare covers are included in Medicare Advantage Plans.  Some Medicare Advantage Plans may modify their benefit packages to offer additional benefits to treat specific conditions.

​

There are some conditions found in Medicare Advantage Plans.  For example, you may need to use doctors who are in the plan’s network (for non-emergency and non-urgent care).  In some cases, you may pay a premium for the plan in addition to the monthly Part B premium.  Plans may offer a $0 premium or might help pay all or part of your Part B premiums.

​

Generally, you can’t buy separate supplemental coverage like Medigap for example.

​

Questions to ask before joining a Medicare Advantage Plan

​

When you are choosing between Original Medicare and Medicare Advantage or between Medicare Advantage Plans, here are some questions to keep in mind.

​

​Providers, hospitals, and other facilities:

​

Are my doctors in the plan’s network? 

Will the plan still cover my visits if my providers are not in-network?

What skilled nursing facilities are in the plan’s network? 

Which specialists, hospitals, and home health agencies are in the plan’s network?

   

​

Access to health care

​

What is the service area for the plan?   If I receive care outside the service area, do I have coverage?

Can I choose my Primary Care Provider (PCP)?

To see a specialist, will I need a referral from my PCP?

​

Costs

​

What are the costs associated with my coverage (premiums, deductibles, copayments)?

Annual maximum out-of-pocket cost?

The copayment cost for services I regularly receive?

If I need to visit an out-of-network provider or facility, how much will it cost?

​

​

Benefits

​

​Does the plan provide any additional service coverage that Original Medicare does not? 

When accessing these benefits, are there rules or restrictions I should be aware of?

​

Prescription drugs

​

Are outpatient prescription drugs covered by the plan?

Does the plan’s formulary include my prescriptions?

Are there any coverage restrictions?

How much will I pay for my drug coverage (premiums, deductibles, copayments)?

What is the cost for brand-name drugs?  Cost for generic drugs?

During the coverage gap, what will I pay for my drugs?

Can I use my Pharmacy?  

​