What’s Included in a Medicare Advantage Plan? A Full Benefits Overview

Medicare Advantage (also known as Medicare Part C) allows seniors to receive their Medicare benefits through private insurers. These plans include offerings like HMOs, PPOs, and others.

But what exactly is included in a Medicare Advantage plan? What benefits, services, and costs should you expect?

In this comprehensive guide, we’ll explain the key components included in most Medicare Advantage plans and policies.

Medicare Advantage 101

First, a quick Medicare Advantage overview:

• Medicare Advantage plans are offered by private insurers approved by Medicare.

• If you join an Advantage plan, the plan provides all of your Part A and Part B coverage.

• Most plans also include prescription drug coverage (Part D).

• You still have Medicare but get your benefits and services through the private plan, not directly through Original Medicare.

• Plans must cover all services Original Medicare covers, except hospice care.

• Many plans offer extra benefits like dental, vision, or wellness programs.

Now let’s look at what’s included in these private Medicare plans.

Health Services

At a minimum, Medicare Advantage plans must cover all the services Original Medicare does, including:

• Inpatient hospital care
• Outpatient services
• Doctor visits
• Preventive services
• Emergency care
• Urgent care
• Skilled nursing facility care
• Home health care
• Lab tests
• Durable medical equipment
• Many prescription drugs

Some types of care, like routine vision, dental, or hearing care, are not covered by Original Medicare so Advantage plans are not required to include them either. But many plans do offer extra benefits like dental, vision, and hearing coverage.

Always check what the plan does and does not include before enrolling.

Provider Network

Most Medicare Advantage plans have a network of approved doctors, specialists, and hospitals you can use.

• PPOs allow you to see out-of-network providers for higher costs.

• HMOs usually require you to stay in-network except emergencies.

Seeing providers outside the network will result in higher out-of-pocket costs or no coverage at all.

It’s essential to check if your preferred doctors, specialists, and health systems are in the plan’s network before enrolling.

Prescription Drug Coverage

A key component included in many Medicare Advantage plans is prescription drug coverage:

• About 9 out of 10 plans include Part D prescription benefits.

• This covers many common prescription medications.

• You pay a monthly premium for the medical and drug coverage together.

• Formulary and pharmacy networks still apply like in stand-alone Part D plans.

If drug coverage is important to you, verify that the plan includes these benefits before signing up.

Maximum Out-of-Pocket Limit

One benefit of Medicare Advantage is that plans must limit your annual out-of-pocket spending for covered medical services.

• The limit amount can vary by plan but must be under $8,300 in 2023.

• Once you hit the plan’s maximum out-of-pocket, you pay nothing for additional covered care.

• Original Medicare does not have an out-of-pocket cap, so your costs could be unlimited.

The tradeoff is that Advantage plans often have higher routine copays or coinsurance than Original Medicare. But the out-of-pocket limit offers financial protection if you have significant medical needs.

Monthly Premiums

In addition to the Part B premium you pay Medicare, most Medicare Advantage plans charge an additional monthly premium. However:

• Some plans have $0 premiums beyond your Part B costs.

• Average premiums range from $20-$120 per month.

• Premiums vary by plan type, benefits offered, and your location.

It’s a good idea to input your medications and preferred providers when comparing plans to see accurate pricing. Higher premiums may be worth it for more robust coverage.

Coordinated Care

Many Advantage plans provide coordinated and integrated care designed to keep you healthier.

Features may include:

• A primary care doctor who oversees your care

• Preventive health and wellness programs

• Chronic condition monitoring and support

• Transition of care after hospital stays

• End-of-life and hospice support

• Nurse advice hotlines

Look for a plan whose care management aligns with your health needs. Those with complex conditions may benefit most.

Additional Benefits

From fitness programs to dental coverage, Advantage plans often include extra benefits and perks. Some additional services to look for include:

• Vision benefits like exams, glasses, or contacts

• Dental cleanings and comprehensive dental care

• Hearing coverage like exams and hearing aids

• Gym memberships, fitness trackers, or wellness programs

• Allowances for eyewear, bathroom safety devices, or other supplies

• Transportation to medical appointments

Make sure to factor in any desired extra benefits when evaluating plan options.

Key Takeaways

The key components included in most Medicare Advantage plans are:

• Coverage of all Original Medicare Part A and Part B services

• Access to in-network providers

• Prescription drug coverage

• Out-of-pocket spending limits

• Monthly premiums

• Coordinated care and case management

• Extra benefits like dental, vision, or hearing

Understanding exactly what’s included helps ensure you select the right Advantage plan for your health and budget needs.