Medicare Advantage (MA) plans provide health insurance coverage through the Medicare program, authorized under Title XVIII of the Social Security Act. Private insurance companies, nonprofits, or other groups permitted to offer MA coverage offer these plans.
These Medicare Advantage plans supplement standard Medicare benefits with additional benefits and availability not offered through standard Medicare, such as routine physical examinations, wellness checkups, and other preventative care. In addition, it is possible to purchase extra inpatient care separately from these MA plans.
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Hospital Indemnity Coverage
- Some MAs offer this coverage plan to provide limited coverage for hospital services. However, MA plans generally do not include coverage for an individual’s medical expenses while in a hospital.
- When a member receives services in a hospital, most MA plans have provisions that allow the member to collect the cost of such services up to some maximum amount. If a member incurs medical expenses while out of the usual hospital setting, they may not be covered by their health plan.
- The amount of such coverage varies significantly among plans. To be covered, it is necessary to have supplemental private insurance or a policy that covers hospitalization.
Physician or Outpatient Coverage
This type of coverage may differ from MA plans offered by different states and or insurance companies. However, most plans include a primary physician responsible for the care of the enrolled members except when under the care of other physicians.
In some cases, this physician can order medical tests and provide medical advice to the participant’s primary care provider. It is intended to help ensure that each member of Medicare Advantage has access to high-quality health care, regardless of where they receive their services.
- This type of coverage is often required by employers who pay the MA plan’s premium, regardless of the employer’s health plan.
- It is an optional policy offered by some MA plans since employers have no legal requirement to contribute to the costs of their employees’ health insurance.
- It is not uncommon for an employer to have more than one plan; a team member may be enrolled in Medicare Advantage and an employer-paid group health plan.
Individual Health Coverage (IHC)
Some Medicare Advantage plans are designed to provide additional benefits such as dental and vision care not covered under standard Medicare. This plan is intended to complement Medicare coverage and not replace it.
The IHC plan sometimes includes wellness benefits such as preventive care and physical exams. It is essential to review the MA plan’s policy carefully to determine if there are eligibility requirements for this portion of coverage. Other plans restrict all additional benefits to health maintenance organizations (HMOs). Most or all of the IHC coverage will be covered in these cases.
Uniform Medical Plan (UMP)
- Business owners purchase this coverage to establish a benefits package for their employees.
- MA plans must be uniformly offered by employers who pay the plan’s premium regardless of their health plan.
- These plans are designed to help members most in need of medical attention by providing enhanced benefits and services to those who qualify.
Outpatient Surgery and Surgical Center Coverage
Some MA plans include outpatient surgery services in their benefits package, while others do not. If a particular plan includes outpatient surgery as part of its coverage, it is usually provided through a separate provider network from standard Medicare. In addition to anaesthesia services, some plans include a surgical centre and surgical supplies as part of their benefits package.
MA plans may offer additional benefits such as prescription drug coverage, vision and dental care, alternative care programs, wellness programs, and other types of preventative care.
These plans help members maintain good health and avoid illnesses and diseases. These types of Medicare Advantage plans are known as managed care MA plans.
Routine Physical Examinations
MA plans usually do not provide routine physical examinations however some MA plans do provide routine physicals to those enrolled in their plan. If physical examinations are provided, it is usually at an added cost. However, routine physicals can be very useful, especially for individuals with illnesses that may require regular follow-ups to monitor for further complications.
Only One MA Plan
Private insurance companies, nonprofits or other groups offer Medicare Advantage plans. However, some areas of the country may only have one MA plan available. It is typically referred to as a “monopoly” and is potentially dangerous because it gives the health plan undue control over the region’s Medicare population.
- Some MA plans provide prescriptions to their members; however, not all plans offer this benefit.
- Each MA plan is required by law to provide members with access to a pharmacy or provider. In some cases, a plan may coordinate with a specific pharmacy to safely and efficiently deliver prescription drugs.
- Community-based MA plans may provide connections to community pharmacies; however, some MA plans do not allow this type of connection.
Emergency Room Coverage
Medicare Advantage plans do not generally include coverage for emergency room services. However, some MA plans offer emergency room coverage under certain circumstances. Therefore, reviewing an individual’s potential plan benefits is essential before signing up for the plan.
Special Needs Plans
- These plans are designed to help those who qualify for Medicare but have been deemed at high risk for complications by their state.
- The primary special needs plans are “benchmark” and “partial capitation.” These plans provide access to high-cost medical services, include additional benefits, and are offered through a closed network.
- People with chronic illnesses, the frail, and other Medicare participants who may be of particular need will likely qualify for a special needs plan.
Many Medicare Advantage plans are designed to be paired with other coverage, most commonly an employer-paid group health plan. In such cases, the MA plan covers primary care, medications and hospitalization benefit up to the limit of coverage under the employer-paid plan. In these cases, the team member is not subject to any retroactive obligation concerning the costs of their Medicare benefits while enrolled in an MA plan.