How Does Medicare Work with Medicare Advantage Plan?

Understanding how Medicare works with Medicare Advantage plans helps individuals make informed decisions about their health care coverage and how it impacts their out-of-pocket expenses, available providers, and covered services. Having a clear understanding of the difference between the two options can help individuals choose the option that best suits their healthcare needs and budget.

Medicare and Medicare Advantage Plan are two separate programs offered by the federal government to provide healthcare coverage to eligible citizens. While Medicare is the original program that provides basic healthcare coverage to those over 65, Medicare Advantage Plan is a private health insurance option that operates within the Medicare framework. In this article, we’ll explore how these two programs work together, and what benefits they offer to seniors and those with disabilities.

What is Medicare and how does it work?

Medicare is a federal health insurance program that provides basic coverage to eligible citizens. It is available to people over 65 and those with certain disabilities. Medicare has four parts:

• Part A covers hospital stays and inpatient care.
• Part B covers doctor visits and outpatient care.
• Part C, also known as Medicare Advantage Plan, is a private health insurance option that operates within the Medicare framework.
• Part D covers prescription drugs.

To receive Medicare coverage, individuals must be enrolled in Parts A and B. While there is no monthly premium for Part A, there is a monthly premium for Part B. In addition, Medicare also requires beneficiaries to pay a deductible and coinsurance for covered services.

What is a Medicare Advantage Plan and how does it work?

Medicare Advantage Plan, also known as Part C, is a private health insurance option that operates within the Medicare framework. These plans are offered by private insurance companies and are designed to provide the same coverage as Medicare Parts A and B. However, they often come with additional benefits and features that are not included in traditional Medicare.

Some of the key benefits of Medicare Advantage Plan include:

• More comprehensive coverage: Many Medicare Advantage Plans offer additional benefits such as vision, dental, and hearing coverage that are not included in traditional Medicare.
• Lower out-of-pocket costs: Medicare Advantage Plans often have lower deductibles, copayments, and coinsurance than traditional Medicare.
• Network restrictions: Medicare Advantage Plans often have a network of participating providers, which means that beneficiaries may have limited choices for doctors and hospitals.

To enroll in a Medicare Advantage Plan, individuals must first be enrolled in Parts A and B of Medicare. They then have the option to enroll in a Medicare Advantage Plan instead of traditional Medicare. Individuals can change their coverage during the annual enrollment period, which takes place between October 15 and December 7.

How does Medicare work with the Medicare Advantage Plan?

When individuals enroll in a Medicare Advantage Plan, they are still enrolled in Medicare Parts A and B. However, instead of receiving coverage through traditional Medicare, they receive coverage through their Medicare Advantage Plan. The Medicare Advantage Plan pays for covered services and acts as the primary payer. In other words, the Medicare Advantage Plan acts as the “middleman” between the beneficiary and Medicare.

Medicare still pays a portion of the cost of the coverage, but the Medicare Advantage Plan is responsible for paying the remaining portion. In addition, Medicare Advantage Plans are required to offer the same coverage as traditional Medicare, with some exceptions.

Medicare Advantage works as a supplement to Original Medicare by offering private fee-for-service plans, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and special needs plans (SNPs) to provide beneficiaries with additional coverage options beyond Original Medicare, allowing them to choose the plan that best fits their healthcare needs and preferences.

What are the benefits of using Medicare with the Medicare Advantage Plan?

There are several benefits to using Medicare with Medicare Advantage Plan, including:

• More comprehensive coverage: Plans offered by Medicare Advantage providers may include vision, hearing, and dental services, as well as drug coverage (Part D) and both Part A and Part B coverage. But it’s important to check with the plan or consult the Centers for Medicare & Medicaid Services (CMS) to understand the specifics of each drug plan and the overall health care coverage.
• Lower out-of-pocket costs: Medicare Advantage Plans often have lower deductibles, copayments, and coinsurance than traditional Medicare.
• Network restrictions: Medicare Advantage Plans often have a network of participating providers, which means that beneficiaries may have limited choices for doctors and hospitals.

FAQs about How Does Medicare Work with Medicare Advantage Plan

1. Do I need to enroll in both Medicare and Medicare Advantage Plan?

Yes, if you want to enroll in a Medicare Advantage Plan, you must first be enrolled in Parts A and B of Medicare.

2. Can I change my coverage from Medicare to Medicare Advantage Plan?

Yes, you can change your coverage from Medicare to Medicare Advantage Plan during the annual enrollment period, which takes place between October 15 and December 7. In addition to the AEP, there are other periods during the year when you may be able to make changes to your Medicare coverage. For example, you may be able to switch to a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (OEP), which runs from January 1st to March 31st each year. Learn more about Medicare Enrollment Periods here.

3. Does Medicare Advantage Plan have network restrictions?

Yes, many Medicare Advantage Plans have a network of participating providers, which means that beneficiaries may have limited choices for doctors and hospitals.

4. Is there a difference in the cost between Medicare and Medicare Advantage Plan?

The cost of coverage will depend on the specific plan you choose and your location. However, Medicare Advantage Plans often have lower deductibles, copayments, and coinsurance than traditional Medicare.

Conclusion:

Medicare and Medicare Advantage Plan are two separate programs that offer healthcare coverage to eligible citizens. Medicare Advantage Plan is a private health insurance option that operates within the Medicare framework and provides the same coverage as traditional Medicare, with some additional benefits. 

When individuals enroll in a Medicare Advantage Plan, they are still enrolled in Medicare Parts A and B, but receive their coverage through their Medicare Advantage Plan instead of traditional Medicare. If you are considering enrolling in a Medicare Advantage Plan, it is important to consider your needs, budget, and preferred healthcare providers to ensure that you choose the best option for you.

Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.