CENTREVILLE — Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. You’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not from Original Medicare.
Covered Services in Medicare Advantage Plans
Medicare Advantage Plans cover all Medicare services. Medicare Advantage Plans may also offer extra coverage. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgently needed care.
Medicare Advantage Plans may offer extra coverage, like vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan.
The plan can choose not to cover the costs of services that aren’t medically necessary under Medicare. If you’re not sure whether a service is covered, check with your provider before you get the service.
You can also ask the plan for a written advance coverage decision to make sure a service is medically necessary and will be covered. If the plan won’t pay for a service you think you need, you’ll have to pay all of the costs if you didn’t ask for an advance coverage decision.
If you need a service that the plan says isn’t medically necessary, you may have to pay all the costs of the service, but you have the right to appeal the decision.
Rules for Medicare Advantage Plans
Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.
However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care). These rules can change each year.
What you pay in a Medicare Advantage Plan
What you pay in a Medicare Advantage Plan depends on several factors. Your out-of-pocket costs in a Medicare Advantage Plan (Part C) depend on:
• Whether the plan charges a monthly premium.
• Whether the plan pays any of your monthly Medicare Part B (Medical Insurance) premium.
• Whether the plan has a yearly deductible or any additional deductibles.
• How much you pay for each visit or service (copayment or coinsurance). For example, the plan may charge a copayment, like $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare.
• The type of health care services you need and how often you get them.
• Whether you go to a doctor or supplier who accepts assignment (if you’re in a PPO, PFFS, or MSA plan and you go out-of-network).
• Whether you follow the plan’s rules, like using network providers.
• Whether you need extra benefits and if the plan charges for it.
• The plan’s yearly limit on your out-of-pocket costs for all medical services.
• Whether you have Medicaid or get help from your state.
Note: Each year, plans establish the amounts they charge for premiums, deductibles and services. The plan (rather than Medicare) decides how much you pay for the covered services you get. What you pay the plan may change only once a year, on Jan. 1.
Drug coverage in Medicare Advantage Plans
You usually get prescription drug coverage (Part D) through the plan. In some types of plans that don’t offer drug coverage, you can join a Medicare Prescription Drug Plan.
You can’t have prescription drug coverage through both a Medicare Advantage Plan and a Medicare Prescription Drug Plan. If you’re in a Medicare Advantage Plan that includes drug coverage and you join a Medicare Prescription Drug Plan, you’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.
How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans
Medigap policies can’t work with Medicare Advantage Plans. If you have a Medigap policy and join a Medicare Advantage Plan (Part C), you have to cancel your Medigap policy.
To cancel your Medigap policy, contact your insurance company. If you leave the Medicare Advantage Plan, you might not be able to get the same Medigap policy back, or in some cases, any Medigap policy unless you have a “trial right.”
If you have a Medicare Advantage Plan, it’s illegal for anyone to sell you a Medigap policy unless you’re switching back to Original Medicare. If you want to switch to Original Medicare and buy a Medigap policy, contact your Medicare Advantage Plan to see if you’re able to disenroll.
If you join a Medicare Advantage Plan for the first time, and you aren’t happy with the plan, you’ll have special rights to buy a Medigap policy if you return to Original Medicare within 12 months of joining.
• If you had a Medigap policy before you joined, you may be able to get the same policy back if the company still sells it. If it isn’t available, you can buy another Medigap policy.
• The Medigap policy can no longer have prescription drug coverage even if you had it before, but you may be able to join a Medicare Prescription Drug Plan (Part D).
• If you joined a Medicare Advantage Plan when you were first eligible for Medicare, you can choose from any Medigap policy.
For more information on Medicare Advantage Plans, go to www.medicare.gov.
Mike Zimmer is president of Bay State Insurance Agency Ltd in Centreville. He is available to answer questions regarding retirement planning, Medicare, Medicare supplements, Medicare Part D (Prescription Plans), dental and vision plans. He may be reached at 410-758-1680. For updates and more information, visit and like the Facebook page Bay State Insurance Agency, LTD.