What Is Medicare Advantage?

What’s covered?

Medicare Advantage plans help cover:

  • All the benefits of Medicare Part A, including hospital stays, skilled nursing care and home health care, but not hospice care. However, because you must be enrolled in Part A to get a Medicare Advantage plan, your Part A benefit helps cover hospice care.
  • All the benefits of Medicare Part B, including doctor visits, outpatient care, screenings, shots and lab tests.
  • Prescription drugs, if Part D prescription drug coverage is included in the Medicare Advantage plan (many do include this coverage). All Special Needs plans include Part D prescription drug coverage.

Some Medicare Advantage plans may also include coverage for extra services such as a fitness benefit or routine hearing and vision care.

Are there limits to coverage?

Coverage limits vary by plan, so you’ll have to look at the specific Medicare Advantage plan’s details to see if there are any coverage limits or exclusions.

Plans that include prescription drug coverage may have additional restrictions, such as the cost-sharing amounts you pay for your medications.

What doctors can I see?

This also varies by plan. In some plans (like HMOs), your health care is coordinated through a primary care physician, who manages the care you receive from doctors, specialists and hospitals within the plan’s network. With these plans, only the services you receive from network providers are covered.

POS and PPO plans are also coordinated care plans like HMOs, but these plans let you receive covered services outside of the plan’s network, generally at a higher cost to you.

Non-network plans (like PFFS plans) let you receive care from any Medicare-eligible doctor or hospital that accepts the plan’s payment terms and conditions before providing you with care. No referrals are ever needed.

All of these Medicare Advantage plan types offer nationwide coverage for emergency care and urgent care. In these situations, you can go to the nearest doctor or hospital.

How much does it cost?

If you join a Medicare Advantage plan, you’ll continue to pay your monthly Part B premium (and Part A premium, if you have one). Some plans may charge an additional monthly premium, but not all do.

You’ll need to look at each Medicare Advantage plan’s details to see what cost-sharing expenses you might have, like deductibles, copays and coinsurance. How much you’ll pay varies by plan. In addition, these plans help protect you from high cost sharing by limiting how much you’ll be required to pay for your health care costs each year through an out-of-pocket limit.

If your Medicare Advantage plan includes prescription drug coverage, you may have additional copays, coinsurance and costs you’ll have to pay for your prescription drugs.

How do I enroll?

You can join a Medicare Advantage plan as soon as you become eligible for Medicare, or during your initial enrollment period. You’ll also need to enroll in Part A and Part B at this time.

Once you’ve joined Part A and Part B, you can’t be refused coverage by any plans in your area that are accepting new members. However, special rules apply to people with end-stage renal disease.

Each private insurance company that offers a Medicare Advantage plan handles the enrollment process for its plans. You’ll need to contact the company directly and ask how to enroll.