How Medicare Advantage Plans Work: An Overview

How Medicare Advantage Plans Work: An Overview

Understanding how Medicare Advantage plans work is essential to tap into the benefits available to you. Original Medicare is considered more widespread than Medicare Advantage in the healthcare industry. Here are important points to remember about how Medicare Advantage plans work.

What Is Covered?

Medicare Advantage plans exist to provide coverage that isn’t available in Original Medicare plans. Original plans, for example, don’t cover fitness programs or hearing loss. Advantage plans cover these items along with over-the-counter (OTC) drugs and wellness solutions. Another difference with Advantage plans is they can be further customized for specific health conditions.

Rules for Medicare Advantage Plans

Pharma and therapeutic companies that work with Medicare Advantage must comply with rules established by Medicare. Each plan has its own out-of-pocket costs but must still comply with maximums charged to patients. Other rules Advantage healthcare partners must follow involve:

  • Referral requirements for seeing a specialist
  • Which doctors and facilities you can visit for non-emergencies or non-urgent care

Factors Affecting Costs for Medicare Advantage Plans

Your Medicare Advantage costs will depend on various factors, such as which doctors are available to you in the plan’s network. Here are some of the main factors that shape your costs for Part C:

  • Does the plan charge a monthly premium? Advantage plans typically have a zero premium. If yours doesn’t, it means you’ll be paying premiums for Parts A, B, and C.
  • Will your plan pay for any of your medical insurance in Medicare Part B? Certain plans can pay for all or part of this coverage, including outpatient care, medical supplies, and specific physician services.
  • Is the deductible annual? Your plan may have multiple deductibles based on add-on coverage.
  • What are your costs for hospital visits or other services? If the plan offers a co-payment, it means it pays for some or all of hospital visit expenses. These payments are often in the ballpark of $10-$20 per visit.
  • Costs will also be shaped by the type of services you use and the frequency with which you use them. Your plan type, such as PPO, will determine which services you can access. If you go outside the plan’s designated network, costs will likely increase.
  • The degree to which you follow the plan’s rules will also affect costs. For example, going outside the network on a regular basis may lead to higher costs.
  • How much of your plan is customized? The more add-ons you include to your coverage, the more you’ll pay.
  • Getting Medicaid and other state help can lower your costs.

Drug Coverage in Medicare Advantage Plans

While most Advantage plans include prescription drug coverage, you may want to explore a separate plan that provides coverage for things that the Advantage plan doesn’t cover. If your plan doesn’t cover certain drugs, you can look into Medicare Medical Savings Account Plans. If you are in a Medicare Advantage HMO or PPO or enroll in a separate Medicare Prescription Drug Plan, you will be disenrolled from Medicare Advantage.

Contact us at Medicare Advisors for more information on how to navigate through the complex world of Medicare.