Do Medicare Advantage Plans Have to Cover Everything Medicare Covers?

Medicare Advantage Plans are health insurance plans offered by private insurance companies that contract with Medicare to provide Medicare Part A and Part B benefits. Medicare Advantage Plans must cover all services that Original Medicare covers, but they can do so with different costs and restrictions. Let's take a closer look at what Medicare Advantage Plans must cover versus what they may optionally cover compared to Original Medicare.

What Original Medicare Covers
Original Medicare consists of Medicare Part A and Part B. Medicare Part A covers hospital care like inpatient stays, skilled nursing facility care, hospice care, and some home health care. Medicare Part B covers doctor visits, preventive services, durable medical equipment, mental health services, and more.

Medicare Part A and Part B premium also cover medically necessary services and supplies used to diagnose or treat medical conditions. Original Medicare covers 80% of approved amounts for covered services after you meet the deductible for Part B. You would need to pay the remaining 20% coinsurance or out-of-pocket costs.

Some key things that Original Medicare coverage covers include:

• Hospital care
• Skilled nursing facility care
• Home health care
• Hospice care
• Doctor visits
• Preventive services like screenings, vaccines, and yearly wellness exams
• Mental health services
• Lab tests
• X-rays
• Durable medical equipment
• Emergency care
• Ambulance transportation

Original Medicare does not cover everything though. Some key exclusions include:

• Routine dental services
• Routine eye exams
• Hearing aids
• Prescription drugs (you need a separate Part D plan for drug coverage)
• Routine foot care
• Acupuncture
• Cosmetic surgery

There are limits on coverage for certain services as well, such as a maximum number of days covered for a hospital stay.

What Medicare Advantage Plans Must Cover
Medicare Advantage Plans must cover all Medicare Part A and Part B services, excluding hospice care. They must offer coverage that is at least equal to what Original Medicare provides.

Medicare Advantage Plans may not charge more for Part A and Part B services than what beneficiaries would pay in Original Medicare. The plans must have provider networks that meet Medicare's standards for adequate access to medical care.

Medicare Advantage Plans are required to cover:

• Hospital care including inpatient, outpatient, observation, and emergency services
• Skilled nursing facility care
• Doctor and specialist visits
• Home health care
• Mental health services
• Clinical laboratory and diagnostic tests
• X-rays and imaging
• Screenings, vaccines, and other preventive care
• Durable medical equipment
• Ambulance transportation
• Emergency care
• Urgently needed care
• Kidney dialysis services

Medicare Advantage Plans must provide coverage for medically necessary services. This includes services used to diagnose or treat an illness or condition that are accepted standards of medical practice.

Plans cannot refuse to pay for emergency or urgently needed care obtained out-of-network. Medicare Advantage enrollees always have the right to appeal a plan's refusal to cover medical services.

What Medicare Advantage Plans May Also Cover
In addition to Original Medicare benefits, Medicare Advantage Plans often include extra benefits not offered by Medicare. Many plans provide additional services to make them more attractive to beneficiaries.

Some additional benefits that Medicare Advantage Plans may offer include:

• Prescription drug coverage
• Routine dental care
• Routine vision care including eye exams and glasses
• Hearing exams and hearing aids
• Wellness programs
• Fitness benefits like a gym membership
• Over-the-counter drug allowances
• Transportation to medical appointments
• Meals following hospitalization
• In-home support services
• Telehealth visits

Medicare Advantage Plans have flexibility in terms of how they design their provider networks, utilize co-pays and coinsurance, and manage utilization through prior authorization and step therapy protocols. Plans can offer different amounts of cost-sharing on certain services.

For instance, a Medicare Advantage Plan may offer $0 co-pays for primary care visits or generic drugs to encourage enrollees to seek preventive care. Plans can offer coverage for services while requiring higher coinsurance than Original Medicare.

Medicare Advantage Plans may also place caps on certain benefits, limit quantities, or exclude coverage of some brands and non-preferred drugs. Not all providers participate in every Medicare Advantage Plan's network either.

Key Takeaways
In summary, Medicare Advantage Plans must cover all services covered by Original Medicare Parts A and B, excluding hospice. Advantage Plans cannot charge more for Medicare services than what you would pay in Original Medicare.

Plans also have flexibility to offer supplemental benefits not covered by Medicare, like vision and dental care. They can utilize different cost-sharing and have their own provider networks and utilization rules.

While Medicare Advantage Plans must cover your Medicare benefits, they may have different costs, restrictions, and coverage rules on certain services. Always check with the plan to confirm details of what is covered and associated costs before receiving care.

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