A Medicare Advantage Plan, sometimes also called Medicare private health plan, is a health insurance program, in the United States, which substitutes Parts A and B of the original Medicare benefits. It is offered by commercial insurance companies whom, in turn, are compensated by the federal government. In contrast to traditional Medicare, they provide all benefits from Parts A and B, but the payments for these are not processed through the Centers for Medicare and Medicaid Services. Most Medicare Advantage plans include prescription drug coverage, for which the federal government makes separate payments.
With the exception of physician and surgeon, Part A of Medicare benefits covers most in-patient hospital services. Part B covers physician and surgeon services, Emergency Room, laboratory, X-rays, diagnostic tests, as well as certain durable medical equipment and supplies.
While Medicare Advantage Plans must cover all of the services that original Medicare covers, hospice care is not one of them. This particular service is covered by Medicare whether or not the patient is enrolled in a Medicare Advantage Plan. Also, emergency and urgently needed care is always covered under all types of Medicare Advantage Plans.
It is important to check whether services, that are not medically necessary under Medicare, are covered, because the plan of choice might choose not to cover them. However, just as they may choose not to cover certain services, they can choose to offer extra coverage; these include vision, hearing, dental, and/or health and wellness programs.
A patient can enroll in a Medicare Advantage Plan if he or she has Medicare Parts A and B, live within the plan’s service area and do not have End-Stage Renal Disease. If ESRD is present, and requires dialysis or a kidney transplant, a Medicare Advantage Plan can be joined after obtaining a Special Needs Plan.
As far as costs, with original Medicare, the patient pays Medicare premium deductibles and coinsurances. This is usually 20% of the cost of out-patient care approved by Medicare. With an Advantage Plan, Medicare premium must be paid, as well as the plan’s premium, if it charges one; it is usually a fixed cost for each office visit.
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