Medicare Advantage FAQs
Medicare Advantage Plans cover almost all Medicare Part A and Part B benefits. Plans must cover all emergency and urgent care, and almost all medically necessary services Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.
Most Medicare Advantage Plans offer coverage for things Original Medicare doesn’t cover, like some vision, hearing, dental, and fitness programs (like gym memberships or discounts). Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness. Plans can also tailor their benefit packages to offer these benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations.
Medicare Advantage Plans must follow Medicare’s rules. Medicare pays a fixed amount for your coverage each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge differ-ent out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to doctors, facilities, or suppliers that belong to the plan’s network for non-emergency or non-urgent care). These rules can change each year. The plan must notify you about any changes before the start of the next enrollment year.
Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you won’t be able to change plans but you can choose a new provider. You generally can’t change plans during the year. Even though the network of providers may change during the year, the plan must still give you access to qualified doctors and specialists. Your plan will make a good faith effort to give you at least 30 days’ notice that your provider is leaving your plan so you have time to choose a new provider. Your plan will also help you choose a new provider to continue managing your health care needs.
You will get two documents each year if you’re on a Medicare Advantage Plan:
- Annual Notice of Change: Includes any changes in coverage, costs, service area, and more that will be effective starting in January. Your plan will send you a printed copy by September 30.
- Evidence of Coverage: Gives you details about what the plan covers, how much you pay, and more. Your plan will send you a notice (or printed copy) by October 15, which will include information on how to access the Evidence of Coverage electronically or request a printed copy.
To join a Medicare Advantage Plan you must live in the plan’s service area and be enrolled in both Parts A & B.
- You can join a Medicare Advantage Plan even if you have a pre-existing condition.
- You can join or leave a Medicare Advantage Plan only at certain times during the year.
- Each year, Medicare Advantage Plans can choose to leave Medicare or make changes to the services they cover and what you pay. If the plan decides to stop participating in Medicare, you’ll have to join another Medicare Advantage Plan or return to Original Medicare.
- Medicare Advantage Plans must follow certain rules when giving you information about how to join their plan.
If you have ESRD, you can enroll in a Medicare Advantage Plan during Open Enrollment (October 15–December 7, 2021). Your plan coverage will start January 1, 2022.
If you join a Medicare Advantage Plan, you’ll usually get drug coverage through that plan. In certain types of plans that can’t offer drug coverage (like Medical Savings Account plans) or choose not to offer drug coverage (like certain Private Fee-for-Service plans), you can join a separate Medicare drug plan. If you’re in a Health Maintenance Organization, HMO Point-of-Service plan, or Preferred Provider Organization, and you join a separate drug plan, you’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.
Talk to your employer, union, or other benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose your employer or union coverage for yourself, your spouse, and dependents and you may not be able to get it back. In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the Medicare Advantage Plan you join. Your employer or union may also offer a Medicare Advantage retiree health plan that they sponsor.
You can’t enroll in (and don’t need) Medigap while you’re in a Medicare Advantage Plan. You can’t use it to pay for any costs (copayments, deductibles, and premiums) you have under a Medicare Advantage Plan.
If you already have Medigap and join a Medicare Advantage Plan, you can drop Medigap. Keep in mind that if you drop Medigap to join a Medicare Advantage Plan, you may not be able to get it back.
Talk to your employer, union, or other benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose your employer or union coverage for yourself, your spouse, and dependents and you may not be able to get it back. In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the Medicare Advantage Plan you join. Your employer or union may also offer a Medicare Advantage retiree health plan that they sponsor.
You can get a decision from your plan in advance to see if it covers a service, drug, or supply. You can also find out how much you’ll have to pay. This is called an “organization determination.” Sometimes you have to do this as prior authorization for your plan to cover the service, drug, or supply.
You, your representative, or your doctor can request an organization determination. Based on your health needs, you, your representative, or your doctor can ask for a fast decision on your organization determination request. If your plan denies coverage, the plan must tell you in writing, and you have the right to appeal.
If a plan provider refers you for a service or to a provider outside the network, but doesn’t get an organization determination in advance, this is called “plan directed care.” In most cases you won’t have to pay more than the plan’s usual cost sharing. Check with your plan for more information about this protection.
Your out-of-pocket costs in a Medicare Advantage Plan depend on:
Whether the plan charges a monthly premium. Many Medicare Advantage Plans have a $0 premium. If you enroll in a plan that does charge a premium, you pay this in addition to the Part B premium.
Whether the plan pays any of your monthly Medicare premiums. Some Medicare Advan-tage Plans will help pay all or part of your Part B premium. This benefit is sometimes called a “Medicare Part B premium reduction.”
Whether the plan has a yearly deductible or any additional deductibles for certain services.
How much you pay for each visit or service (copayments or coinsurance). Medicare Advan-tage Plans can’t charge more than Original Medicare for certain services, like chemotherapy, dialysis, and skilled nursing facility care.
The type of health care services you need and how often you get them.
Whether you get services from a network provider or a provider that doesn’t contract with the plan. If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your plan may not cover your services, or your costs could be higher. In most cases, this applies to Medicare Advantage Plans, Health Maintenance Organizations and Preferred Provider Organizations.
Whether you go to a doctor or supplier who accepts assignment (if you’re in a Preferred Pro-vider Organization or Private Fee-for-Service plan, or Medical Savings Account plan and you go out of network).
Whether the plan offers extra benefits (in addition to Original Medicare benefits) and if you need to pay extra to get them.
The plan’s yearly limit on your out of pocket costs for all Part A and Part B medical services. Once you reach this limit, you’ll pay nothing for Part A and Part B covered services.
Whether you have Medicaid or get help from your state through a Medicare Savings Program.
To learn more about your costs in specific Medicare Advantage Plans contact the plan, or visit Medicare.gov/plan-compare.
