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What is Medicare Advantage?


Medicare Advantage, also known as Medicare Part C, is an all-in-one alternative to original Medicare.

Private insurance companies offer Medicare Advantage plans that Medicare approves. They bundle Part A hospital coverage and Part B doctor and outpatient services and usually Part D prescription coverage into one comprehensive plan.

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In 2023, more than half (51 percent) of Medicare beneficiaries chose to get their coverage through a Medicare Advantage plan, rather than original Medicare, according to KFF, formerly the Kaiser Family Foundation.

If you decide to get coverage through a Medicare Advantage plan, you’ll still have to enroll in Medicare Parts A and B. Then you can choose a Medicare Advantage plan and sign up with a private insurer.

You may have several options, depending on your location. The average Medicare beneficiary has 43 Medicare Advantage plans to choose from in 2024, according to KFF.

What do Medicare Advantage plans cover?

The federal government requires Medicare Advantage plans to cover everything that Medicare Parts A and B cover, but they may have different deductibles and copayments. Most Medicare Advantage plans cover prescription drugs, too. Many plans help pay for services that original Medicare does not cover, such as routine dentalhearing and vision care.

Some Medicare Advantage plans provide additional coverage to people with chronic conditions. Provisions include meal delivery or grocery allowance, shower grips and wheelchair ramps for your home, plus transportation to and from doctors’ offices.

Unlike original Medicare, which covers any provider who accepts Medicare, most Medicare Advantage plans have a provider network and may charge more, or they may not cover doctors or facilities outside the plan’s network.

The two most common types of Medicare Advantage plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

  • HMOs typically let you choose a primary care doctor to direct your care; you may need a referral from that doctor to see a specialist. You usually don’t have coverage for out-of-network providers except in emergencies.
  • PPOs also have a network of doctors and facilities, but you usually don’t need a referral to see a specialist. You may have coverage if you go outside the plan’s network, but you’ll usually have higher copayments and other out-of-pocket costs.

What are the costs for Medicare Advantage plans?

You must enroll in Medicare Parts A and B before you can get Medicare Advantage. You need to pay the Part B premium, which is $164.90 a month for most people in 2023; $174.70 in 2024. You must also pay the Part A premium if required although most Medicare beneficiaries don’t have to pay a premium for Part A.

You may have to pay a monthly premium to the Medicare Advantage insurer. The average monthly premium for Medicare Advantage enrollees is $18 in 2023; $18.50 in 2024, but more than half the plans charge no premium. Some plans have a premium giveback and refund some money that otherwise would go toward Medicare Part B premiums.

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Even though Medicare Advantage plans must provide at least as much coverage as original Medicare, you may have different out-of-pocket costs. For example, you may have a daily copayment for the first few days in a hospital, such as $325 for each of the first five days as a hospital inpatient, rather than the Part A hospital deductible of $1,600 per benefit period in 2023 ($1,632 in 2024).

These copayments can vary by plan. You’ll also have copayments or coinsurance for your prescription drugs.

Unlike original Medicare, Medicare Advantage plans have an annual maximum out-of-pocket spending limit for services covered under Parts A and B, which must be $8,300 or less for in-network health services in 2023 and $12,450 or less for in-network and out-of-network services combined. Those limits rise to $8,850 and $13,300 in 2024. Some plans have lower spending limits.

Who is eligible for Medicare Advantage?

To join a Medicare Advantage plan, you must be enrolled in Parts A and B of Medicare. The plan cannot refuse your application, regardless of your health needs.

In the past, you couldn’t sign up for Medicare Advantage if you had permanent kidney failure, known as end-stage renal disease. But the 21st Century Cures Act of 2016 changed the rules, and as of Jan. 1, 2021, people with kidney failure can choose either original Medicare or Medicare Advantage.

Medicare Advantage plans cannot charge you higher premiums, deductibles or copays based on your current state of health or preexisting conditions. Some Medicare Advantage plans, called special needs plans (SNPs), provide coverage for certain groups of people, including plans that focus on coverage for those with chronic conditions, such as diabetes, heart failure or kidney failure.

You can sign up for Medicare Advantage or switch plans only at certain times, including when you first enroll in Parts A and B and during open enrollment each year from Oct. 15 to Dec. 7 for new coverage starting Jan. 1. If you have a Medicare Advantage plan, you can switch to a different plan or change from Medicare Advantage to original Medicare, from Jan. 1 to March 31 each year.

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Keep in mind

Medicare Advantage premiums, copayments, covered services, drug coverage, lists of doctors and other benefits can change every year. Make it a point to review costs and coverage for MA plans available in your area every year during open enrollment

The Plan Finder makes it easy to compare costs and coverage for the MA plans available in your zip code. It also lists premiums, benefits, copayments and out-of-pocket costs for your medications. You usually need to contact the plan directly to make sure your doctors and other providers are covered.

Medigap, the Medicare supplement insurance that people often buy to help cover original Medicare’s deductibles and copayments, doesn’t work with Medicare Advantage plans. You can’t buy a Medigap policy while you’re in a Medicare Advantage plan. You must pay the Medicare Advantage copayments and deductibles yourself.

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Video: What’s the Difference Between Original Medicare and Medicare Advantage?

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