If you enroll in a Medicare Advantage Plan, you may be wondering - does Medicare still pay anything toward my coverage if I have a private Medicare Advantage Plan?
Medicare Advantage Plans provide an alternate way to get your Medicare benefits compared to Original Medicare. But how does that change what Medicare pays for?
Read on for an overview of how Medicare coordinates with Medicare Advantage Plans and what costs are covered when you have this type of plan.
What are Medicare Advantage Plans?
Medicare Advantage Plans are private health plans that contract with Medicare to provide your Medicare Part A and Part B benefits. They are offered by insurance companies approved by Medicare.
When you join a Medicare Advantage Plan, you still have Medicare and get the same Medicare Part A and B benefits, but the plan administers your coverage.
Medicare Advantage Plans must cover all medically necessary services Original Medicare does. However, the costs and rules for getting care may differ.
Most Medicare Advantage Plans also include prescription drug coverage under Medicare Part D. There are HMO, PPO, and PFFS types of Medicare Advantage Plans with varying costs and coverage rules.
Over 28 million Medicare beneficiaries, or about 48% of the total, are enrolled in Medicare Advantage Plans as of 2022.
Does Medicare Pay for Medicare Advantage Coverage?
Yes, Medicare does usually pay a portion for your Medicare Advantage Plan benefits. Here is how it works:
- You continue paying your monthly Part B premium just like in Original Medicare
- Medicare pays your Medicare Advantage Plan a set amount per month to cover your care
- The plan provides all your Medicare Part A and Part B benefits
The monthly payment Medicare provides for your coverage is called a “capitation” amount. It is a fixed fee based on average expected healthcare costs in your area.
So in summary - Medicare pays part of the costs for your medical benefits, but the Medicare Advantage Plan or coverage options administers and pays for covered services.
Your Medicare Advantage Plan Costs
With Medicare Advantage Plans, your costs may include:
- Monthly Medicare Part B premium
- Medicare Advantage Plan premium if not a $0 premium plan
- Copays or coinsurance for covered medical services
- Prescription drug deductibles and copays if Part D is included
Many Medicare Advantage Plans have $0 monthly premiums, but the Part B premium still applies. Costs vary by plan.
What Costs Does Original Medicare Cover?
If you were enrolled in Original Medicare, here is what Medicare would pay:
- Part A:Medicare pays 100% of inpatient hospital, skilled nursing facility, and some home health costs after you meet the deductible.
- Part B:Medicare pays 80% of covered outpatient services after you pay the Part B deductible. You would owe 20% coinsurance.
- Part D:You pay premiums for a private prescription drug plan that covers medications.
So with Original Medicare, Medicare pays a share of covered services and you owe deductibles, premiums, and coinsurance amounts.
Medicare Advantage Special Rules
While your Medicare Advantage Plan coordinates your Medicare benefits, here are some costs and services Medicare will pay for:
- Medicare hospice benefits- Medicare (not the Medicare Advantage Plan to get) will pay for hospice care if you need it.
- Clinical research studies- Medicare covers some costs associated with qualifying clinical trials.
- New benefits required by law- If new Medicare benefits are added, Medicare will pay the Medicare Advantage Plan to include these.
- Kidney transplants- If you need a kidney transplant, Medicare will cover this even if your plan does not.
So in these special cases, Medicare may have to pay or directly cover specific costs related to your care while you have a Medicare Advantage Plan.
Limits with Medicare Advantage
While enrolled in a Medicare Advantage Plan:
- You cannot purchase a separate Medicare Supplement (Medigap) policy.
- You must follow the plan's rules and use in-network providers except in emergencies or urgent cases.
- Medicare will not cover services the Medicare Advantage Plan does not reimburse if you go out-of-network.
Make sure to understand how your Medicare Advantage Plan's coverage rules and network impact your benefits.
Changing from Medicare Advantage to Original Medicare
You have the option to switch from a Medicare Advantage Plan back to Original Medicare during Medicare's Annual Election Period from October 15 to December 7 each year. You also may qualify for a Special Enrollment Period.
If you switch back to Original Medicare, Medicare will resume paying its share of covered healthcare costs instead of the Medicare Advantage Plan.
Medicare Advantage vs. Medigap
Since Original Medicare leaves gaps in coverage, many enrollees get a Medigap Plan to cover deductibles, coinsurance, copays and excess charges. How do costs with Medigap compare?
- Medicare pays plan a monthly amount for your coverage
- $0 premium plans may be available
- Out-of-pocket costs like copays apply
- Medicare pays its share of covered services
- You pay the insurer a monthly Medigap premium
- Medigap covers Medicare gaps like coinsurance
While Medigap Plans have premiums, Medicare Advantage can have $0 premium options and extras like dental or vision. Weigh the pros and cons for your situation.
Does Medicare Pay for Medicare Advantage - Key Takeaways
- Medicare pays a fixed monthly amount to Medicare Advantage Plans for your Part A and Part B benefits.
- You continue paying your Medicare Part B premium and any Medicare Advantage Plan premium.
- Medicare Advantage Plans administer coverage but Medicare pays part of the costs.
- Medicare pays 100% of Original Medicare costs after deductibles, coinsurance, whereas Medicare Advantage has different costs.
- Medicare will pay for some services like hospice and clinical trials even if you have a Medicare Advantage Plan.
- You cannot use a Medigap policy if enrolled in Medicare Advantage.
- Medicare resumes paying its share of costs if you switch back to Original Medicare.
So in summary, yes Medicare still contributes payment for your coverage even when you have a Medicare Advantage Plan. Understanding how Medicare coordinates with Medicare Advantage helps give you a complete picture of how these plans work.
We’re Here to Help
You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Premier 360 Solutions a Call at (714) 248-8255. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.
What is a Medicare Advantage Plan?
Medicare Advantage Plans, sometimes called Medicare Part C, are health plan options that are approved by Medicare but run by private companies. They include all services covered by Original Medicare (Part A and Part B) and usually Part D Medicare drug coverage. Many Medicare Advantage Plans also offer extra benefits that Original Medicare doesn't cover.
Do Medicare Advantage Plans cover prescription drugs?
Most Medicare Advantage Plans include Medicare Part D prescription drug coverage. This means you won't have to purchase a separate Part D Plan if you enroll in an Advantage Plan that includes drug coverage.
What benefits are included in Medicare Part B?
Medicare Part B covers doctor visits, preventive services, lab tests, X-rays, ambulance transportation, mental health services, and medical equipment and supplies. Most Part B services require a 20% coinsurance payment after the yearly deductible is met.
Does Original Medicare pay anything if you have a Medicare Advantage Plan?
No, if you have a Medicare Advantage Plan, also known as Medicare Part C, your healthcare services are covered by the Medicare Advantage Plan and not by Original Medicare. Original Medicare will not pay for any services or drugs that are covered by your Medicare Advantage Plan.
What are my Medicare options?
Your Medicare options include Original Medicare (Part A and Part B) or a Medicare Advantage Plan (Part C). You can also choose to get Medicare prescription drug coverage (Part D) if you want.
What is a Medicare Advantage Plan?
A Medicare Advantage Plan is an alternative to Original Medicare. It is a type of Medicare health plan offered by private insurance companies that provides you with all of your Medicare Part A and Part B coverage, and often includes Medicare prescription drug coverage (Part D) as well.
Can I get Medicare prescription drug coverage?
Yes, if you have Original Medicare, you can get Medicare prescription drug coverage by joining a separate Medicare drug plan. If you have a Medicare Advantage Plan, your prescription drug coverage is typically included in your plan.
What does Medicare cover for dental services?
Original Medicare does not cover routine dental services, such as cleanings, fillings, or dentures. However, some Medicare Advantage Plans may offer dental coverage as part of their benefits package.
Do I usually have to pay anything for Medicare Part A and Part B?
For Medicare Part A, most people do not have to pay a premium if they or their spouse paid Medicare taxes while working. However, for Part B, you will generally have to pay a monthly premium.
Do I have to join a separate Medicare drug plan if I have a Medicare Advantage Plan?
If you have a Medicare Advantage Plan that includes prescription drug coverage, you do not need to join a separate Medicare drug plan. Your prescription drugs will be covered by your Medicare Advantage Plan.
What is a Medicare Part C Health plan?
A Medicare Health plan, also known as Medicare Part C, is an alternative to Original Medicare. It is a type of Medicare Advantage Plan offered by private insurance companies that provides you with all of your Medicare Part A and Part B coverage, and often includes extra benefits such as vision, dental, and prescription drug coverage.