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Oct 26, 20236 min read

Do Medicare Advantage Plans Have to Cover Everything Original Medicare Covers?

Updated: Oct 10

Medicare Advantage (also called Medicare Part C) represents an increasingly popular alternative to original Medicare for health coverage. But do Medicare Advantage Plans have to include all the same benefits as traditional Medicare Parts A and B?

The short answer is yes - with a few small exceptions, Medicare Advantage Plans must cover all services included under original Medicare. However, how plans deliver these benefits can differ. Understanding what Medicare Advantage Plans are required to cover provides helpful insights when evaluating options.

Medicare Advantage Coverage Requirements

Medicare sets guidelines that private insurers must follow when offering Medicare Advantage Plans. Key rules include:

Must cover all Part A and Part B benefits - This encompasses hospitalization, outpatient care, preventive services, emergency services, and any additional benefits added to original Medicare by Congress going forward.
At least match cost sharing levels - For example, MA plans must cover hospital stays beyond 60 days even though original Medicare stops at 60. The plan can charge daily copays for extended days.
Provide emergency and urgent care worldwide - Plans must cover these services worldwide, not just within a plan's service area. The copay cannot exceed $90 for worldwide emergency care.
No denial for pre-existing conditions - Medicare Advantage Plans cannot refuse applicants or exclude coverage of pre-existing medical conditions.
Meet annual out-of-pocket maximum requirements - Plans cap enrollee in-network out-of-pocket spending each year. The limit is $8,300 in 2023. Plans may offer lower limits.

Medicare conducts extensive reviews to ensure plans adhere to benefit and policy requirements before certifying them for participation. This oversight safeguards appropriate coverage.

What Medicare Advantage Plans Don't Have to Cover

There are a couple services Medicare Advantage Plans don't cover that you'd need to get through original Medicare:

Hospice care - If enrolled in an MA plan and requiring hospice care, you must return to original Medicare in order to receive hospice coverage.
Clinical research studies - Original Medicare covers approved clinical trials and studies while Medicare Advantage Plans do not. You would need to switch back to original Medicare temporarily if participating in a study.

Aside from these two exceptions, Medicare Advantage does not allow significant deviations from original Medicare benefits. Services can be delivered in different ways through private networks and coordinated care models but the basics remain the same.

How Medicare Advantage Plans Structure Benefits

While required to include all Part A and B benefits, Medicare Advantage Plans have flexibility to:

Charge different copays or coinsurance - For example, a doctor visit might be $10 under original Medicare but $25 under an MA plan. As long as the overall out-of-pocket costs don't exceed limits, plans can set varied cost sharing.
Use network providers - Many MA plans have networks and steering to network doctors lowers costs. Seeing out-of-network providers will incur higher copays or no coverage.
Require authorizations - Plans may mandate approval of certain services or specialists before covering, unlike original Medicare. This allows plans to manage utilization and costs.
Provide benefits differently - Plans aren't required to cover services exactly as Medicare does but must offer comparable overall value. Telehealth offers new flexibility.

While structured uniquely by each insurer, all Medicare Advantage Plans fundamentally include the same benefits as Parts A and B. Understanding variations provides insight into comparing and selecting plans.

What Extra Benefits Do Medicare Advantage Plans Offer?

Beyond covering original Medicare benefits, most Medicare Advantage Plans include valuable extra benefits like:

Dental care
Vision coverage
Hearing aids
Gym memberships
Transportation to appointments
Over-the-counter allowances
Home healthcare
Telehealth services
Wellness programs
Caregiver supports

These supplemental benefits represent a key attraction of Medicare Advantage for many enrollees. However, plan options and specific extra coverage varies. Those with greater healthcare needs may find certain plans more robust than others.

How Prescription Drugs Are Covered

One major difference between original Medicare and Medicare Advantage relates to prescription drug coverage:

Original Medicare - Does not include drug coverage under Parts A and B. You must purchase a separate standalone Part D Plan for medications.
Medicare Advantage - Most plans include Part D prescription drug benefits with medical coverage, excluding Medical Savings Accounts and a few PPOs. Enrollees do not need a separate Part D Plan.

Integrated drug benefits simplify coordination under Medicare Advantage. Those requiring multiple prescriptions may find type of Medicare Advantage more convenient and cost effective. Understanding each plan's formulary and pharmacy network remains important.

Appealing Denied Services with Medicare Advantage

If your Medicare Advantage Plan denies coverage of a service as not medically necessary, you have the right to appeal:

Reconsideration and review from the MA plan directly
Review by an independent review entity if first appeal denied
Hearing before Administrative Law judge if amount meets requirements

Plans must continue covering disputed service through completion of appeals. MA enrollees also receive guaranteed issue rights to Medigap Plans if returning to original Medicare after appeals exhaust.

The Takeaway

In summary, while structured differently, Medicare Advantage Plans must include all the same benefits as original Medicare Parts A and B, excluding just hospice and clinical trials. This comprehensive coverage combined with additional plan benefits makes MA an attractive option for beneficiaries if network providers meet healthcare needs.

FAQs

Do Medicare Advantage Plans have to cover everything Medicare covers?

Medicare Advantage Plans, also known as Medicare Part C, are required to provide the same coverage as Original Medicare (Part A and Part B). However, they may have different rules, costs, and restrictions. Some Medicare Advantage Plans may offer additional benefits beyond what is covered by Original Medicare, such as prescription drug coverage, dental services, or vision services.

What is Medicare coverage?

Medicare coverage refers to the healthcare services and supplies that are covered by the Medicare program. It includes hospital insurance (Part A), medical insurance (Part B), and prescription drug coverage (Part D). Medicare coverage can help pay for a wide range of medical services, including doctor visits, hospital stays, preventive care, and prescription drugs.

Do Medicare Advantage Plans cover Part B premium?

Medicare Advantage Plans may cover the Part B premium, but this can vary depending on the specific plan. Some Medicare Advantage Plans may offer a $0 premium, meaning you would not have to pay a separate premium in addition to your Part B premium. It is important to review the details of the Medicare Advantage Plan to understand the premium costs and coverage options.

Do Medicare Advantage Plans cover prescription drugs?

Many Medicare Advantage Plans offer prescription drug coverage as part of their benefits. These plans are known as Medicare Advantage Prescription Drug (MA-PD) plans. They provide coverage for both medical services and prescription drugs, eliminating the need for a separate Medicare Part D prescription drug plan.

Can I join a Medicare Advantage Plan if I have Original Medicare?

Yes, you can join a Medicare Advantage Plan if you have Original Medicare (Part A and Part B). You have the option to switch from Original Medicare to a Medicare Advantage Plan during certain enrollment periods. It is important to compare the coverage and costs of different plans to choose the one that best meets your healthcare needs.

Do Medicare Advantage Plans offer dental services?

Some Medicare Advantage Plans may offer dental services as part of their additional benefits. These dental services may include routine cleanings, fillings, and certain preventive treatments. However, the coverage and limitations may vary between different Medicare Advantage Plans, so it is important to review the plan details.

Can I have both Medicare Advantage and Medicare Supplement insurance Health Plan?

No, you cannot have both Medicare Advantage and Medicare Supplement insurance at the same time. Medicare Advantage Plans provide an all-in-one alternative to Original Medicare, while Medicare Supplement insurance (Medigap) is designed to fill the gaps in coverage left by Original Medicare. You must choose between one of these options.

Do I have to join a separate Medicare drug plan if I have a Medicare Advantage Plan?

No, you do not need to join a separate Medicare drug plan if you have a Medicare Advantage Plan that includes prescription drug coverage. Medicare Advantage Prescription Drug (MA-PD) plans provide both medical and prescription drug coverage in a single plan.

Do Medicare Advantage Plans or Part C offer additional coverage options?

Yes, Medicare Advantage Plans may offer additional coverage options beyond what is provided by Original Medicare. These additional benefits can include vision care, hearing aids, fitness programs, and other wellness services. The specific coverage options can vary between different Medicare Advantage Plans.

Does Medicare Part A and B cover all medical services?

Medicare Part B covers a wide range of medical services, including doctor visits, outpatient care, preventive services, and some medical equipment. However, there are certain services that are not covered by Part B, such as dental care, routine eye exams, and personal care items. It is important to review the specific coverage limitations of Medicare Part B.