Medicare Advantage Plans are a type of Medicare health plan offered by a private company that contracts with Medicare to provide all your Part A and Part B benefits paid for by Original Medicare.
These plans utilize a series of copays (set dollar amount for specific services) and coinsurances (percentage they must pay for specific services) which can be found in each plan's summary of benefits. Each Medicare Advantage plan has its own list of copays and coinsurances so benefits
can vary widely between available plans.
Medicare Advantage plans have a Maximum-Out-of-Pocket (MOOP), which make them unique compared to all other parts of Medicare. All of the plan's copays and coinsurances apply towards the MOOP, giving the beneficiary an absolute limit on their annual spending for all covered services. Prescription drug costs and non-covered benefits do not apply toward the MOOP.
Medicare Advantage beneficiaries must utilize a network of providers for coverage based on the type of plan they are enrolled in:
• Health Maintenance Organization (HMO) - beneficiaries must utilize in-network providers to receive coverage for services, except in emergency or urgent care situations.
• Preferred Provider Organizations (PPO) - beneficiaries can utilize the plan's network of providers and facilities to pay the lowest copays/coinsurances for covered services. They are able to go outside of the network but will pay higher out of pocket costs, and they must still see a provider/facility that participates in the Medicare program.
Medicare Advantage plans take the place of Original Medicare when it comes to billing. Providers bill the plan directly for services and the plan will pay them back directly, leaving the client to pay any applicable copays or coinsurances for covered services. If there an issue with billing, both the provider and the client can reach out to the plan for assistance.
Medicare Advantage plans include all of the extras from Original Medicare, plus other benefits which make the plans very attractive to some beneficiaries. These extra benefits may include (benefits vary by plan) dental, vision, hearing, fitness, transportation, chiropractic, acupuncture, annual physical, post-discharge meals, telemedicine, over-the-counter supplies, and many more. Beneficiaries can refer to their plan's summary of benefits for a full list of extra benefits.
Many Medicare Advantage plans include Part D coverage built into the coverage, so the client receives their health and Rx benefits from one company. These Medicare Advantage Prescription Drug plans are referred to as MAPDs. Clients with a PFFS Medicare Advantage plan have the option to purchase a stand-alone Part D plan.