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, and they bundle together parts A (hospital coverage) and B (doctor and outpatient services) and usually Part D prescription drug coverage into one comprehensive plan. More than 40 percent of Medicare beneficiaries choose to get their coverage through a Medicare Advantage plan, rather than original Medicare.
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 39 Medicare Advantage plans to choose from in 2022, according to the Kaiser Family Foundation.
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 also help pay for services that original Medicare does not cover, such as routine dental, hearing and vision care.
Some Medicare Advantage plans provide additional coverage to people with chronic conditions, such as meal delivery, shower grips and wheelchair ramps for your home, plus transportation to and from doctors’ offices.
Unlike original Medicare, which covers any providers who accept Medicare, most Medicare Advantage plans have a provider network and may charge more or not cover doctors or facilities that are outside of the plan’s network.
The two most common types of Medicare Advantage plans are health maintenance organizations and preferred provider organizations (PPOs). With HMOs, you typically choose a primary care doctor who directs your care, and you may need a referral from your primary care 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.
You must enroll in Medicare parts A and B before you can get Medicare Advantage, and you need to pay the Part B premium, which is $170.10 a month for most people in 2022. 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 also may have to pay a monthly premium to the Medicare Advantage insurer. The average monthly premium for Medicare Advantage enrollees is $19 in 2022, but more than half the plans charge no premium.
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 the hospital (such as $325 for each of the first five days as a hospital inpatient), rather than the Part A hospital deductible of $1,556 per benefit period in 2022. 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 $7,550 or less for in-network health services in 2022 and $11,300 or less for in-network and out-of-network services combined. Some plans have lower spending limits.
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 since Jan. 1, 2021, people with kidney failure can now 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 already have a Medicare Advantage plan, you can also switch to a different plan or change from Medicare Advantage to original Medicare, from Jan. 1 to March 31 each year.
Updated May 24, 2022
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