Medicare Advantage costs and coverage

Medicare Advantage Plan overview

When choosing a Medicare Advantage Plan, be aware of the different cost-sharing you may face. Costs in MA Plans are often different from in Original Medicare, and may come with additional rules. Consider each plan carefully before enrolling.

  • Medicare Part B premium: In an MA Plan, you generally must pay the Part B premium. Plans may also charge you an additional premium. In some cases, the plan may pay part of your Part B premium.
  • Deductible: MA Plans may charge you a deductible for services, including inpatient, outpatient, and prescription drugs. Deductibles will vary by plan.
  • Copayment: MA Plans usually charge a copayment (copay) for doctor’s visits, instead of the 20% coinsurance you pay under Original Medicare. Keep in mind that MA Plans cannot charge higher copays than Original Medicare for certain care, including chemotherapy, dialysis, and skilled nursing facility (SNF) care.
  • Maximum out-of-pocket (MOOP) limit: All plans must include a maximum out-of-pocket limit. This means the amount you pay out of pocket is capped for the year, which protects you from excessive costs if you need a lot of care or expensive services. These limits are typically high, and they include copays and deductibles.

In addition to the above, remember that MA Plans have different coverage rules.

  • Many plans cover services only if you receive them from doctors, hospitals, and pharmacies that are in the plan’s network. Before you join an MA Plan, make sure your doctors (or other providers you may want to use in the future) are in the network and that they are accepting new patients from the plan. Keep in mind that doctors and hospitals may leave the plan at any time, but you can only leave an MA Plan during an enrollment period if you want to avoid incurring a penalty.
  • Though MA Plans must cover the same health services that Original Medicare covers, they may ask you to pay more for certain services or require that you take certain steps before they will pay for your care. For example, a plan may require your provider to ask the plan’s permission before giving you certain services, or require more formal referrals to see specialists or prior authorization for certain services.

Remember: you cannot buy a Medigap policy to supplement an MA Plan and cover cost-sharing. Medigap policies only work with Original Medicare.