Medicare Advantage Coverage

Inpatient Coverage 

Medicare Advantage plans provide at least the same level of coverage that Original Medicare provides under Part A. In general, Part A coverage includes inpatient care in a hospital, skilled nursing facility care, nursing home care that is inpatient care in a skilled nursing facility that doesn’t provide custodial (activities of daily living support) or long-term care, hospice care, and home health care. It is important to understand your cost sharing as it may be different depending on the Medicare Advantage plan you choose. For example, your hospice care benefits will be covered by Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Outpatient Coverage

Medicare Part B coverage includes out-patients services that are medically necessary and preventive services. Medically necessary services include those that are to diagnose or treat an illness and preventive services are those to prevent illness or early detection of disease. Similar to Part A coverage, Medicare Advantage plans must provide the same level of coverage as Original Medicare. However, the cost sharing may be different depending on the Medicare Advantage plan you choose. Services include: 

• Doctor visits include primary care doctors and specialists
• Preventative tests and vaccines, including flu shots
• Laboratory tests and X-rays
• Both inpatient and outpatient mental health services
• Ambulance services in an emergency
• Durable medical equipment such as infusion pumps and hospital beds
• Physical therapy
• Occupational therapy
• Speech and language pathology

Medicare Advantage Extra Benefits: Dental, Hearing, and Vision 

Coverage of these benefits vary by individual Medicare Advantage plan and it’ll be important to look carefully at what’s in and what’s out. For example, for dental, cleaning and extraction may be covered with different co-pays depending on the plan.

Some plans may have benefits included as part of your premium, but may also include “buy ups,” which essentially means that you’d have to pay an additional premium to get some of those benefits.

And finally, you should expect that while these benefits may be part of your MA plan, they are likely administered through third parties, much as you have experienced with your health coverage through your employer.

Dental Coverage

Many Medicare Advantage plans cover dental services beyond what is covered through Original Medicare. However, Medicare Advantage plans are not required to offer supplemental (i.e. above and beyond the coverage required by Original Medicare), therefore you are likely to find that coverage of supplemental dental benefits vary by plans. Some Medicare Advantage Plans may also charge an additional premium for this added benefit. As a result, if you are comparing dental coverage, you will need to compare plans individually to understand what they cover.

What Does Dental Coverage Cost Me Under Medicare Advantage?

Typically benefits covered under Original Medicare are included without additional costs to you. If the Medicare Advantage plan includes supplemental dental coverage that may also be included as part of your total premium, and therefore may not always require a separate premium. And finally, importantly, depending on the plan, you may have cost sharing and some coinsurance on specific services directly paid to the dental provider.

Hearing Coverage

It is increasingly common for Medicare Advantage plans to add coverage for hearing aids and fitting exams, in addition to the Medicare covered diagnostic and balance exams. These additional hearing benefits may have cost-sharing and annual or biannual limits associated with them and may require you to rely on specific providers who contract with the individual Medicare Advantage plan. As with all of these additional benefits that are beyond those covered through Original Medicare, the offering will vary by Medicare Advantage Plan.

What Does Hearing Coverage Cost Me With My Medicare Advantage Plan?

Costs associated with Medicare covered hearing services and additional hearing benefits, like hearing aids will vary by individual Medicare Advantage plan. 

Vision Coverage

Vision coverage is a very popular extra benefit that some Medicare Advantage plans offer. As we age so do our eyes which may require routine vision care. Original Medicare Part A and B offer limited coverage for vision care which doesn’t include routine eye exams. Medicare Advantage plans that offer vision typically cover routine eye exams, fittings for frames and contact lenses and materials such as eyeglasses, contacts. 

What Does Vision Coverage Cost Me With My Medicare Advantage Plan?

Cost sharing for vision coverage may vary by individual Medicare Advantage plan. 

Medicare Advantage Prescription Drug Plan (MA-PD)

A Medicare Advantage Prescription Drug plan (MA-PD) is a Medicare Advantage (Part C) plan that includes prescription drug coverage.

What are Preventive Services?

Preventive services are provided to prevent illness or detect illness at an early stage, when treatment is likely to be most effective. These services range from lab tests, exams, screenings, shots, vaccinations, and monitoring programs. Some services are provided at no cost to you while others have cost sharing. Most of these services are covered under Medicare Part B as they are outpatient services. Take time to educate yourself about the frequency and coverage of these services to help navigate through them with your doctor.

You may be wondering who identifies what a Medicare preventive service is. This is the responsibility of the U.S. Preventive Services Task Force, founded in 1984. The task force is an independent, volunteer panel of national experts in prevention and evidence-based medicine. Since 1998, the task force has been assembled by the Agency for Healthcare Research and Quality (AHRQ) to provide ongoing scientific, administrative, and dissemination support to the task force. This group works to improve the overall health of Americans by making recommendations about preventive services such as screenings, counseling services, and preventive medications. On an annual basis, the task force creates a report to the U.S. Congress that provides guidance on gaps in preventive services and recommends priority areas for further research.

Welcome to Medicare

There are two main office visits that may initiate preventive services. The first is your one time “Welcome to Medicare” and the second is your “Yearly Wellness Visit”. When calling to make an appointment, remember to let the doctor’s office know that you are scheduling your “Welcome to Medicare” or “Yearly Wellness Visit”. Since these are preventive visits, you will not pay for the office visit or services as long as your doctor accepts assignment with Medicare and doesn’t provide non-preventive services during the visit. Assignment is an agreement between your doctor and Medicare. Your doctor agrees to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and to not bill you for any more than the Medicare deductible and coinsurance.

The “Welcome to Medicare” visit will take place during the first 12 months that you have Medicare Part B. This appointment is an opportunity for you and your doctor to discuss your medical and social history, learn about preventive services, and receive referrals for other care, if necessary.

Yearly Wellness Visit

The “Yearly Wellness Visit” takes place if you’ve had Medicare Part B for longer than 12 months. During this visit, you and your doctor will touch base to discuss your overall health. Your doctor will ask you to complete a “Health Risk Assessment” and will help the doctor evaluate your current health and risk factors. This information will allow the doctor to create a personalized preventive care plan to help keep you healthy. In addition to the Health Risk Assessment, the doctor will also discuss the preventive services including education and counseling on screenings and necessary shots or vaccines. It is important to remember that this visit isn’t a physical exam. A physical exam is not considered a Medicare preventive service.

Resources to Learn More About Medicare Preventive Services

• The Medicare and You Handbook is a great resource to identify these services, cost, and frequency guidelines.
• Preventive Services Checklist – Take this checklist with you when you go to a doctor’s appointment to ask your doctor if you are up-to-date on your preventive services.
• Medicare’s Preventive & Screening Services List, with Description
• Video on Medicare Preventive Services

Medicare Advantage Special Needs Plan

Special Needs Plans (SNPs) are a type of Medicare Advantage plan that limits enrollment to Medicare beneficiaries who meet certain eligibility criteria. These plans’ benefits are tailored to meet the needs of people with specific conditions or characteristics.

The Centers for Medicare & Medicaid Services (CMS) has designated three types of Special Needs Plans (SNPs):

• Chronic Condition Special Needs Plans (C-SNP): These plans serve beneficiaries with certain severe or disabling chronic conditions, such as cancer, chronic heart failure, or HIV/AIDS. C-SNPs may target a single chronic condition or more than one condition.
• Dual-Eligible Special Needs Plans (D-SNP): These plans serve people who have both Medicare and Medicaid benefits (also known as “dual eligibles”).
• Institutional Special Needs Plans (I-SNP): These plans serve those living in an institution (such as a nursing home) or who need nursing care at home.

What Is Covered with a Medicare Special Needs Plan?

Medicare Advantage Special Needs Plans include coverage for hospital services (Medicare Part A), medical healthcare needs (Medicare Part B), and prescription drugs (Medicare Part D) through a single plan.

Like other Medicare Advantage plans, Special Needs Plans are available through private insurance companies that are approved by Medicare. All Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare, which includes Part A and Part B. Some Medicare Advantage plans may also cover benefits beyond what Original Medicare covers, and your Medicare plan options and benefits can vary, depending on where you live.

Some Special Needs Plans include care-coordination services to help you better understand your condition and stick to your treatment regimen. Or you might have access to wellness programs to help with a special diet or other lifestyle activities that can help improve your condition.

Chronic-Condition Special Needs Plans (C-SNPs) may include provider networks with physicians and hospitals that specialize in treating the specific condition of its members, or they may have formularies that are tailored to include the prescription drugs that treat that illness.

If you’re enrolled in a Special Needs Plan for dual eligibles (D-SNPs), there may be certain social services available to help you coordinate your Medicare and Medicaid benefits.

It’s important to note that, with an SNP, you still get all the coverage that is otherwise included with Original Medicare, Part A and Part B, and Medicare Part D. The Special Needs Plan simply offers extra coverage to help you better manage your particular situation, whether that’s living in a nursing home, coordinating your Medicare and Medicaid benefits, or treating a serious chronic illness.

One key difference between a Special Needs Plan (SNP) and other types of Medicare Advantage plans is that all SNPs must cover prescription drugs. In contrast, other Medicare Advantage plans (for example, HMOs and PPOs) may or may not include prescription drug coverage, depending on the specific plan.

Chronic Condition Special Needs Plan (C-SNP) 

If you are on or are shopping for a Medicare Advantage (MA, also known as Part C) plan and have a chronic illness, you may be eligible to enroll in a Special Needs Plan (SNP) designed specifically for members with your condition. These are known as Chronic Condition Special Needs Plans (C-SNPs) by Medicare, and are created to manage the needs of members who have one of the qualifying conditions, such as diabetes, chronic obstructive pulmonary disease (COPD), certain types of cancer, etc.

The benefits of a C-SNP are that the health plan provides care coordination, a network of physician specialists, clinical case management, and community resources specifically tailored to and focused on the condition. C-SNPs have formularies designed to offer prescription drugs that are commonly used for that condition. Another advantage to enrolling in a C-SNP is that it may also cover extra services tailored to the chronic condition.

It’s important to note that the availability of C-SNPs and the conditions that they cover vary from county to county, your area may not have a C-SNP for your particular condition. However, if you are interested in exploring your C-SNP options, you can use Ask Claire’s Find My Plan tool to include them in your plan comparison.

What Conditions Qualify for Coverage Under a Chronic Condition Special Needs Plan (C-SNP)?

The Center for Medicare and Medicaid Services allows for C-SNPs to be offered for individuals with these conditions.

• Chronic alcohol and other dependence
• Autoimmune disorders
• Cancer (excluding pre-cancer conditions)
• Cardiovascular disorders
• Chronic heart failure
• Dementia
• Diabetes mellitus
• End-stage liver disease
• End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
• Severe hematologic disorders
• HIV/AIDS
• Chronic lung disorders
• Chronic and disabling mental health conditions
• Neurologic disorders
• Stroke

According to the Centers for Medicare & Medicaid Services (CMS), each Medicare SNP limits its membership to people in one of these groups or a subset of one of these groups. For example, a Medicare SNP may be designed to serve only people diagnosed with congestive heart failure. The plan might include access to a network of providers who specialize in treating congestive heart failure. It would also feature clinical case management programs designed to serve the special needs of people with this condition. The plan’s drug formulary would be designed to cover the drugs usually used to treat congestive heart failure. People who join this plan would get benefits specially tailored to their condition, and have all their care coordinated through the Medicare SNP.

Now, it’s important to note that your area may not have a C-SNP for your particular condition, but if you are interested in exploring these options, our plan finder tool will allow you to include them in your plan comparison.