An alternative insurance plan to Original Medicare is Medicare Advantage which will contain the same federally required coverage as Original Medicare (Parts A and B) bundled with optional additional coverage which Parts A and B do not cover.
What Variables Can Affect Medicare Advantage Coverage?
The private insurance plans offered through Medicare Advantage will likely be affected by state which, in turn effects prices and coverage benefits. All Advantage plans must cover emergency, urgent care and all medically necessary services offered under Original Medicare. It’s likely you will need to use health care providers that participate in the plan’s network. Advantage coverage options are vast, and the most common plans offered are:
- Health Maintenance Organization (HMO)
- Plan Preferred Provider Organization (PPO)
- Local or Region Plan
- Special Needs Plan (SNP)
- Plan Private-Fee-For Service (PFFS) Plan
What Kind of Medicare Coverage and Plans do People Typically Select?
Year over year Medicare Advantage enrollment varies by state but appears to be growing in popularity and is projected to make up 50% of the beneficiaries by 2025 vs. the Original Medicare plan. Of the four most popular Advantage plans about 62% of Advantage enrollees are in HMOs, followed by 31% enrolled in local PPO’s. Most Advantage enrollees (90%) select plans that have prescription drug coverage.
What do Medicare Advantage Plans Not Cover?
Coverage under an Advantage plan can be highly variable depending on enrollee coverage selection. You must have Parts A and B to be eligible for coverage under Part C. For the most part, however, Advantage plans won’t cover any of the following treatments or services:
- Alternative medicine
- Clinical trials, out of country care
- Cosmetic surgery
When it’s the only care required exceptions can also be applied to: personal care (like bathing, dressing), non-emergency transportation, and custodial care (like housekeeping, meal preparation). Plan coverage can also be denied if plan rules are not followed. This would occur in scenarios when an enrollee failed to get approval before receiving treatment or if the treatment was determined to not be medically necessary.
- Medicare Advantage Plans Cover all Services, Medicare.
- What Percent of New Medicare Beneficiaries are Enrolling in Medicare Advantage, Kaiser Family Foundation.
- Medicare Advantage in 2021, Kaiser Family Foundation.