Medicare Advantage: Eligibility, Costs, Coverage

What Are the Different Types of Plans?

Some of the plans fall under the Health Maintenance Organization (HMO) category, which is a plan where you get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some HMO plans, you may be able to go out-of-network for certain services, but usually at a higher cost. This is called an HMO with a point-of-service (POS) option.

Like most HMOs, you choose a primary care doctor and need a referral to see a specialist. Certain services, like yearly screening mammograms, don’t require a referral.

If your doctor or other health care provider leaves the plan’s network, your plan will notify you. You may choose another doctor in your plan’s network. If you get health care outside the plan’s network, you may have to pay the full cost, so it’s important that you follow the plan’s rules, like getting prior approval for certain services when needed.

The second type is a Preferred Provider Organization (PPO). They have networks of doctors, other health care providers, and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost. You’re always covered for emergency and urgent care.

Prescription drugs are also covered in most cases. If you want Medicare drug coverage, you must join a PPO plan that offers prescription drug coverage because it’s not always included.

You do not need to choose a primary care doctor or get a referral to see a specialist under a PPO in most cases. 

Who Can Join a Medicare Advantage Plan?

You must meet these conditions to join a Medicare Advantage Plan:

• You have Part A and Part B of Medicare (known as Original Medicare)
• You live in the plan’s service area.
• You can join a Medicare Advantage Plan even if you have a pre-existing condition, except for End-Stage Renal Disease (ESRD), which falls under special rules.
• You can only join or leave a Medicare Advantage Plan at certain times during the year.
• Each year, Medicare Advantage Plans can choose to leave Medicare or make changes to the services they cover and what you pay. If your plan decides to stop participating in Medicare, you’ll have to join another Medicare Advantage Plan or return to Original Medicare.
• Medicare Advantage Plans must follow certain rules when giving you information about how to join their plan. 

What If I Have Other Coverage? 

In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the Medicare Advantage Plan you join. Your employer or union may also offer a Medicare Advantage retiree health plan that they sponsor. 

Can I Have Medicare Advantage and a Medicare Supplement Insurance (Medigap) Policy?

No. You can’t enroll in (and don’t need) a Medicare Supplement Insurance (Medigap) policy while you’re enrolled in a Medicare Advantage Plan. You can’t use it to pay for any expenses (copayments, deductibles, or premiums) you have under a Medicare Advantage Plan. You can’t have both.

What Do I Pay for a Medicare Advantage Plan?

Your typical out-of-pocket costs depend on:

• Whether the plan charges a monthly premium. Some Medicare Advantage plans do not. Any premiums would be in addition to your Part B premium.
• Whether the plan pays any of your monthly Medicare premiums. Some Medicare Advantage Plans will help pay all or part of your Part B premium. This benefit is sometimes called a “Medicare Part B premium reduction.”
• Whether the plan has a yearly deductible or any additional deductibles for certain services would add to the potential cost of the plan.
• How much you pay for each visit or service (copayments or coinsurance). Medicare Advantage Plans can’t charge more than Original Medicare for certain services, like chemotherapy, dialysis and skilled nursing facility care.
• The type of health care services you need and how often you get them.
• Whether you get services from a network provider or a provider that doesn’t contract with the plan. If you go to a doctor, other health care provider, facility or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your services may not be covered at all, or your costs could be higher. In most cases, this applies to Medicare Advantage HMOs and PPOs.
• Whether you go to a doctor or supplier who accepts assignment (if you’re in a Preferred Provider Organization, Private Fee-for-Service Plan, or Medical Savings Account Plan and you go out-of-network).
• Whether the plan offers extra benefits (in addition to Original Medicare benefits) and if you need to pay extra to get them.
• The plan’s yearly limit on your out-of-pocket costs for all Part A and Part B medical services. Once you reach this limit, you’ll pay nothing for Part A- and Part B-covered services.
• Whether you have Medicaid or get help from your state.

How Do I Know What’s Covered?

You can get a decision from your plan in advance—which is called “organization determination”—to see if a service, drug, or supply is covered. You can also find out how much you’ll have to pay.

If your plan denies coverage, the plan must tell you in writing, and you have the right to an appeal. If a plan provider refers you for a service or to a provider outside the network, but doesn’t get an organization determination in advance, this is called “plan directed care.” In most cases you won’t have to pay more than the plan’s usual cost sharing. Check with your plan for more information about this type of protection.

Is There a Way to Compare Plans?

The Medicare Plan Finder tool  will help you sort through the details of the various plan options. Log in to your MyMedicare account to save your information when you compare plans.