Medicare Advantage Plans provide all of your Part A and Part B benefits, including new benefits that come from laws or Medicare policy decisions. Plans must cover all emergency and urgent care (both physical and mental), and almost all medically necessary services Original Medicare covers. Medicare Advantage Plan benefits exclude clinical trials and hospice services. But if you’re in a Medicare Advantage Plan, Original Medicare will still help cover your costs for hospice care, and some costs for clinical research studies.
The plan can choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered, check with your provider before you get the service.
With a Medicare Advantage Plan, you may have coverage for things Original Medicare doesn't cover, like fitness programs (gym memberships or discounts) and some vision, hearing, and dental services (like routine check ups or cleanings). Plans can also cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs that Part D doesn’t cover, and services that promote your health and wellness. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations.
Plans can also tailor their benefit packages to offer additional benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Although you can check with a Medicare Advantage plan before you join to see if they offer these benefit packages, you’ll need to wait until you join the plan to see if you qualify.
Most plans include Medicare drug coverage (Part D) . In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan.
In 2023, the standard Part B premium amount is $164.90 ($174.70 in 2024) (or higher depending on your income).
If you need a service that the plan says isn't medically necessary, you may have to pay all the costs of the service. But, you have the right to appeal the decision.
If you have a Medicare Advantage Plan, you have the right to an organization determination, either orally or written, to see if a service, drug, or supply is covered. Contact your plan to get one and follow the instructions to file a timely appeal.
If a plan provider refers you for a covered service or to a provider outside the network, but doesn’t get an organization determination in advance, this is called “plan directed care.” In most cases, you won’t have to pay more than the plan’s usual cost sharing. Check with your plan for more information about this protection.
You don’t have to pay more than the plan’s usual cost-sharing for a service or supply if a network provider didn’t get an organization determination and either of these is true:
- The provider gave you or referred you for services or supplies that you reasonably thought would be covered.
- The provider referred you to an out-of-network provider for plan-covered services.
Contact your plan for more information. Get your plan's contact information.