What Are Medicare Advantage Plans Required to Cover?
Navigating Medicare Advantage Plans can be complex. If you’re wondering what Medicare Advantage plans are required to cover, the answer is straightforward: they must include hospital (Part A) and medical insurance (Part B) as Original Medicare does, and may add benefits such as prescription drugs, vision, and dental care.
Our guide outlines these mandatory and additional coverages to help you make an informed choice.
Key Takeaways
- Medicare Advantage Plans must cover hospital (Part A) and medical insurance (Part B) services akin to Original Medicare, with potential added benefits such as prescription drugs (Part D), vision, dental, and hearing coverage.
- Medicare Advantage Plans may have network limitations impacting the choice of healthcare providers and out-of-pocket costs, and most plans have an annual cap on these costs providing financial protection.
- Enrollment in Medicare Advantage Plans is time-sensitive, with specific periods for initial sign-up, annual plan changes, and open enrollment, and missing these windows can lead to penalties or limited coverage options.
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Mandatory Coverage in Medicare Advantage Plans
Legally, Medicare Advantage Plans are obliged to cover both hospital insurance (Part A) and medical insurance (Part B) services.
This means they provide the same coverage as Original Medicare, with the addition of certain other potential benefits, such as:
- Vision and dental care
- Hearing aids
- Over-the-counter medications
We will outline the specific coverage details of Part A, Part B, and Part C services, including the Part B premium, below.
Hospital Insurance (Part A)
Part A of Medicare Advantage Plans covers:
- Inpatient hospital stays
- Care in a skilled nursing facility
- Hospice care
- Certain home health care services
This part of the plan ensures that you are covered for essential inpatient care services, like stays in a skilled nursing facility or certain home health care, as well as emergency care, thereby reducing your out-of-pocket costs for these services.
Medical Insurance (Part B)
Medicare Part B covers the following services:
- Doctors’ services
- Outpatient care
- Medical supplies
- Preventive services like screenings and vaccines
- Some home health care services
It also covers a wide range of home health care services, such as skilled nursing care and doctor visits required for home health care. This ensures that beneficiaries have access to essential medical services without bearing the entire financial burden.
Additional Benefits Offered by Medicare Advantage Plans
Beyond the benefits covered under Original Medicare, Medicare Advantage Plans may offer extra benefits. These may include prescription drug coverage, vision, hearing, and dental services to promote a healthy lifestyle.
We will further analyze these potential coverage benefits below.
Prescription Drug Coverage
One significant advantage of Medicare Advantage Plans is that most include prescription drug coverage, also known as Part D. This coverage includes various plans like:
- HMO
- PPO
- Private Fee-for-Service (PFFS)
- Special Needs (SNPs) plans
Depending on the plan, beneficiaries get access to a range of prescription drugs, including Medicare drug coverage for Alzheimer’s disease, at a negotiated price, potentially resulting in lower costs.
Vision, Hearing, and Dental Services
Medicare Advantage plans may offer coverage for:
- Vision services, including routine vision exams and prescription contact lenses
- Dental services, including preventive and comprehensive dental services
- Hearing services, including hearing aids
These services are not covered under Original Medicare. However, it’s important to note that Medicare Advantage plans may impose certain restrictions, such as yearly caps on vision coverage and limits on the frequency of covered services for hearing.
Network Limitations and Provider Choices
The network of providers is a significant consideration when selecting a Medicare Advantage Plan. These plans often have network limitations that can affect the choice of doctors and medical offices, as well as the out-of-pocket costs.
We will proceed to discuss the differences between in-network and out-of-network providers, as well as other providers, below.
In-Network Providers
In-network providers are those healthcare providers that have agreed to work with your Medicare Advantage Plan and deliver services at a mutually agreed-upon rate.
Using in-network providers can lead to lower costs as these providers often have lower expense caps for doctor and hospital services.
Plus, Medicare Advantage Plans are required to have an annual limit on out-of-pocket costs, offering financial protection to beneficiaries.
Out-of-Network Providers
Out-of-network providers refer to those healthcare providers that do not belong to the plan’s network. Using out-of-network providers can potentially lead to higher medical care expenses, and certain services may not be covered, resulting in higher out-of-pocket costs.
Hence, considering the network of providers and their Medicare contract is a key aspect when selecting a Medicare Advantage Plan.
Cost Considerations for Medicare Advantage Plans
Costs related to Medicare Advantage Plans can significantly differ, depending on coverage, type of plan, and provider network. These costs include premiums, deductibles, copays, and out-of-pocket maximums.
We will go into more detail about these costs below.
Premiums
Premiums are the monthly cost of the Medicare Advantage Plan, which can vary depending on the level of coverage and potential benefits.
However, some plans offer lower premiums but may impose more limitations on providers and services.
Hence, not just the premium but other costs and potential benefits should be considered when choosing a plan.
Deductibles and Copays
Deductibles and copays are two important terms to understand when it comes to insurance coverage.
Here’s what you need to know:
- Deductibles refer to the annual out-of-pocket amount that a beneficiary must pay before the insurance coverage kicks in.
- Copays are fixed payments for specific services or items, such as doctor’s visits.
- The amounts for both deductibles and copays can vary across different plans.
Hence, these costs should be considered along with premiums and potential benefits when comparing plans.
Out-of-Pocket Maximums
Out-of-pocket maximums are the maximum amount a beneficiary will pay for covered services in a year. This provides a financial safety net for beneficiaries, ensuring that they do not have to bear the entire financial burden of their healthcare.
The average limit for in-network services can vary depending on the plan.
Comparing Medicare Advantage Plans
Not just the costs, but also the coverage and provider networks should be considered when comparing Medicare Advantage Plans. This will ensure that you find a plan that not only fits your budget but also provides the healthcare services you need.
In the sections below, we will discuss how to compare plans cover, coverage, costs, and provider networks.
Coverage
When comparing coverage across different Medicare Advantage Plans, consider both the mandatory coverage as well as the potential additional benefits offered.
This includes:
- Hospital insurance (Part A)
- Medical insurance (Part B)
- Prescription drug coverage
- Any potential extra benefits like vision, hearing, and dental services
Make sure to also review the potential restrictions or limitations on these services.
Costs
When comparing costs, consider the following:
- Premiums
- Deductibles
- Copays
- Out-of-pocket maximums
These costs can vary across different plans, so it’s important to calculate the overall out-of-pocket costs for your specific healthcare needs. Make sure to also consider any potential late enrollment penalties or additional costs for out-of-network providers.
Provider Networks
When comparing provider networks, consider the size of the network, the availability of your preferred healthcare providers, and their geographic accessibility.
Keep in mind that using out-of-network providers can potentially lead to higher medical care expenses, so it’s important to ensure that your preferred healthcare providers are part of the network.
Enrollment in Medicare Advantage Plans
You can enroll in Medicare Advantage Plans during certain periods such as the Initial Enrollment Period, Annual Enrollment Period, and Medicare Advantage Open Enrollment Period.
It’s important to be aware of these periods to ensure that you don’t miss the opportunity to enroll in or make changes to your plan.
These enrollment periods, which may include contract renewal, will be discussed in more detail in the sections below.
Initial Enrollment Period (IEP)
The Initial Enrollment Period (IEP) is a 7-month window surrounding your 65th birthday or when you first become eligible for Medicare. This is the first opportunity to enroll in a Medicare Advantage Plan, and missing this window can lead to a monthly late enrollment penalty.
Therefore, make sure to enroll as soon as you’re eligible to avoid any penalties.
Annual Enrollment Period (AEP)
The Annual Enrollment Period (AEP) occurs from October 15 to December 7 each year. During this period, you can change your Medicare Advantage Plan or enroll in a new plan.
This is an important window to review your current plan and make any necessary changes to ensure that it continues to meet your healthcare needs.
Medicare Advantage Open Enrollment Period
The Medicare Advantage Open Enrollment Period runs from January 1 to March 31. During this period, if you’re already enrolled in a Medicare Advantage Plan, you can switch to a different plan or return to Original Medicare.
This is another opportunity to review your plan and make changes if your healthcare needs have changed.
Summary
In conclusion, Medicare Advantage Plans offer a wide range of coverage, from mandatory hospital and medical insurance to potential additional benefits like prescription drug coverage and dental, vision, and hearing coverage.
However, these plans also come with various costs, including premiums, deductibles, copays, and out-of-pocket maximums, and often have network limitations that can affect your choice of healthcare providers.
Therefore, when considering a Medicare Advantage Plan, it’s important to fully understand the coverage, costs, and provider networks.
Make sure to compare different plans, consider your specific healthcare needs, and enroll during the designated enrollment periods. With careful consideration and planning, you can find a plan that provides the healthcare services you need at a cost you can afford.
Frequently Asked Questions
→ What is the biggest advantage of Medicare Advantage?
The biggest advantage of Medicare Advantage plans is that they offer comprehensive coverage for lower premiums.
→ What do Medicare Advantage plans usually cover?
Medicare Advantage plans usually cover hospital insurance, medical insurance, and may include additional benefits such as prescription drug coverage, vision care, hearing care, and dental care.
→ What are the 4 things Medicare doesn’t cover?
Medicare typically won’t cover certain items and services, such as dental care, routine vision and hearing exams, and long-term care.
→ What is the difference between Original Medicare and Medicare Advantage Plans?
The main difference between Original Medicare and Medicare Advantage Plans is that Original Medicare is provided by the government and consists of Part A (hospital insurance) and Part B (medical insurance).
Medicare Advantage Plans are offered by private insurance companies and may include extra benefits like prescription drug coverage.
ZRN Health & Financial Services, LLC, a Texas limited liability company
Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.