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Medicare Advantage Plans must cover all of the services that 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. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgently needed care

The plan can choose not to cover the costs of services that aren’t medically necessary under Medicare. If you’re not sure whether a service is covered, check with your provider before you get the service.

Most Medicare Advantage Plans offer coverage for things that aren’t covered Original Medicare, like vision, hearing, dental, and wellness programs (like gym memberships). Plans can also cover more extra benefits than they have in the past, including services like transportation to doctor visits, over-the-counter drugs, adult day-care services, and other health-related services that promote your health and wellness. Plans can also tailor their benefit packages to offer these new benefits to certain chronically ill enrollees. These packages will provide benefits customized to treat those conditions. Check with the plan to see what benefits are offered and if you qualify. Most include

Medicare Drug Coverage (Part D)

. In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan.

In 2021, the standard Part B premium amount is $148.50 (or higher depending on your income).

If you need a service that the plan says isn’t medically necessary, you may have to pay all the costs of the service. But, you have the right to appeal the decision.

If you have a Medicare Advantage Plan, you have the right to an organization determination to see if a service, drug, or supply is covered. Contact your plan to get one and follow the instructions to file a timely appeal. You also may get plan directed care. This is when a plan provider refers you for a service or to a provider outside the network without getting an organization determination in advance.

You don’t have to pay more than the plan’s usual cost-sharing for a service or supply if a network provider didn’t get an organization determination and either of these is true:

• The provider gave you or referred you for services or supplies that you reasonably thought would be covered.
• The provider referred you to an out-of-network provider for plan-covered services.

Types of Medicare Advantage plans

There are different types of Medicare Advantage plans to choose from, including:

1. Health Maintenance Organization (HMO). HMO plans utilize in-network doctors and require referrals for specialists.
2. Preferred Provider Organization (PPO). PPO plans charge different rates based on in-network or out-of-network services.
3. Private Fee-for-Service (PFFS). PFFS plans are special payment plans that offer provider flexibility.
4. Special Needs Plans (SNPs). SNPs help with long-term medical costs for chronic conditions.
5. Medical Savings Account (MSA). MSA plans are medical savings accounts paired with high deductible health plans.

Contact a Medicare Advantage plans insurance expert

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