Does Original Medicare Pay Anything if You Have an Medicare Advantage Plan?

If you enroll in a Medicare Advantage Plan, you may wonder - does Medicare still pay anything toward my healthcare if I'm in a private Medicare Plan? Understanding how Medicare coordinates with Medicare Advantage Plans can help explain what costs you may be responsible for.

How Medicare Works with Medicare Advantage Plans

First, it's helpful to understand how Medicare interacts with Medicare Advantage Plans. Here are some key points:

·        Medicare Advantage Plans are run by private insurance companies approved by Medicare.

·        If you join a Medicare Advantage Plan, you still remain in the Medicare program.

·        Medicare may pays a fixed monthly amount per enrollee to the insurance company offering your Medicare Advantage Plan.

·        The plan must provide all coverage under Medicare Parts A and B. Most plans also include Part D drug coverage.

·        For services covered under Original Medicare, the plan determines what you will pay out-of-pocket through copays, deductibles, and coinsurance.

So in summary - Medicare still pays for your coverage if you're in a Medicare Advantage Plan, but it pays the plan rather than directly paying healthcare providers for services.

Your Costs with Medicare Advantage

While Medicare pays a base amount each month for your coverage, you will likely have some out-of-pocket costs under your Medicare Advantage Plan:

·        Monthly premiums - Most plans charge a monthly premium. The average is about $20 per month. Some plans have a $0 premium.

·        Copays - A set fee you pay for healthcare services, like a $5 or $10 copay when you see the doctor. Plans typically use copays rather than 20% coinsurance.

·        Deductibles - Some plans charge an annual deductible (often $0 to low amounts).

·        Coinsurance - The percent you pay for certain services, such as 10% to 20% of the total cost.

·        Out-of-pocket maximum - Plans limit your total yearly costs for medical services. Once you reach this amount, your plan pays 100% of covered services.

So while Medicare helps cover costs through the monthly payment to your Medicare Advantage Plan, you'll likely have some out-of-pocket fees to pay throughout the year depending on your medical care needs.

What Medicare Pays For

For any services covered under Original Medicare Parts A and  Part B, Medicare Advantage Plans generally pay the full Medicare-approved amount, minus your copays or coinsurance. This includes:

·        Inpatient hospital stays

·        Outpatient services and procedures

·        Doctor visits

·        Preventive services like cancer screenings

·        Emergency care

·        Urgently needed care

·        Skilled nursing facility care

·        Home health services

·        Durable medical equipment

·        Lab tests, X-rays, MRIs

Medicare requires Medicare Advantage Plans to cover these medically necessary services. Plans can't charge more for these services than Original Medicare does.

The plan may also cover extra benefits not included under Original Medicare that Medicare does not directly pay for, such as:

·        Dental care

·        Vision care

·        Hearing exams and hearing aids

·        Gym memberships

·        Over-the-counter items

·        Transportation to doctors

But for all of your basic Medicare coverage, Medicare pays its share of costs through the monthly capitated fee to your Medicare Advantage insurer.

Paying Your Medicare Part B Premium

There is one payment that Medicare does not cover for Medicare Advantage enrollees - your Medicare Part B premium.

Everyone enrolled in Medicare must pay their standard Part B premium each month to remain covered. This premium is $164.90 per month for most beneficiaries in 2023. Higher income enrollees pay more.

You must continue paying your Part B premium after joining a Medicare Advantage Plan. This is automatically deducted from your Social Security check or directly billed by Medicare if you don't get Social Security. Not paying this premium could result in termination of your coverage.

Some Medicare Advantage Plans may help cover part of your Part B premium as an extra benefit. But in general, you remain responsible for paying your Part B premium to Medicare.

Changing Medicare Advantage Plans

At certain times of year, you can switch between Medicare Advantage Plans or go back to Original Medicare. During these enrollment periods, Medicare will automatically pay the new coverage you choose rather than your previous Medicare Advantage Plan.

Key enrollment periods include:

·        Medicare Advantage Open Enrollment Period - January 1 to March 31

·        Medicare Advantage Disenrollment Period - January 1 to February 14

·        Annual Election Period - October 15 to December 7

So you can change the plan Medicare pays each year, or switch back to Original Medicare and a Part D  Medicare drug coverage if you find that works better for your needs.

Conclusion

In summary, Medicare continues contributing toward your healthcare costs even when you're in a Medicare Advantage Plan by making monthly payments to your Medicare Advantage insurer. However, you'll likely have additional out-of-pocket costs through copays and coinsurance depending on the plan. And you must continue paying your Medicare Part B premium. Understanding how Medicare coordinates with Medicare Advantage Plans can help you budget for any costs you may be responsible for.

We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Bourgeois Insurance a Call at (985) 803-8999. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.

FAQS

Does Medicare pay anything if you have a Medicare Advantage health plan compared to Original Medicare?

 Yes, Medicare will still pay for certain covered services if you have a Medicare Advantage health plan. However, the amount Medicare pays may differ depending on the specific plan and the services provided.

What is Original Medicare?

 Original Medicare refers to the traditional fee-for-service Medicare program. It includes Medicare Part A (hospital insurance) and Part B (medical insurance). These parts offer coverage for a wide range of healthcare services and supplies.

Does Medicare cover all health plans?

 No, Medicare does not cover all types of health plans. However, it does cover Medicare Advantage Plans, which are offered by private insurance companies approved by Medicare. These plans provide an alternative way to receive Medicare benefits.

What do Parts A and B of Medicare cover?

 Medicare Part A covers hospital stays, skilled nursing facilities, hospice care, and some home health services. Part B covers doctor visits, preventive services, outpatient care, and medical supplies.

Can I have both Original Medicare and Medicare Advantage?

No, you cannot have both Original Medicare and Medicare Advantage at the same time. You must choose between the two options. However, you may switch from Original Medicare to Medicare Advantage or vice versa during certain enrollment periods.

Do all Medicare Advantage Plans include prescription drug coverage?

 No, not all Medicare Advantage Plans include prescription drug coverage. Some plans offer this coverage as part of their benefits, while others may require you to enroll in a separate Medicare drug plan to get prescription drug coverage.

What types of services do Medicare Advantage Plans cover?

 Medicare Advantage Plans must cover all the services that Original Medicare covers. Additionally, they may offer extra benefits such as vision, hearing, dental services, and prescription drug coverage. Each plan may have different coverage options, so it's important to review the specific plan details.

Do I have to pay a premium for Medicare Advantage Plans?

 Yes, most  type of Medicare Advantage Plans require you to pay a monthly premium in addition to your Medicare Part B premium. The amount of the premium can vary depending on the plan and the level of coverage it provides.

Can Medicare Advantage Plans offer supplemental coverage?

 Yes, Medicare Advantage Plans may offer supplemental coverage, also known as additional benefits. These benefits can include coverage for services not covered by Original Medicare, such as dental, vision, hearing, and fitness programs.

Do Medicare Advantage Plans help pay for prescription drugs?

Yes, many Medicare Advantage Plans offer prescription drug coverage as part of their benefits. However, the specific drugs covered and the cost-sharing arrangements can vary between plans. It's important to review the plan's formulary and cost-sharing details to understand how prescription drug coverage works.