Medicare Advantage Plans medicare plans in az must cover all of the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgently needed care.
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.
Most Medicare Advantage Plans offer extra coverage, like vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan. In 2019, the standard Part B premium amount is $135.50 (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.
You (or a provider acting on your behalf) can request to see if an item or service will be covered by the plan in advance. Sometimes you must do this for the service to be covered. This is called an “organization determination.” If your plan denies coverage, the plan must tell you in writing.
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.
The original Medicare program (which began in 1966) consists of Part A (hospital insurance) and Part B (medical insurance). If you’re enrolled in original Medicare and want Part D prescription drug coverage (a benefit that was added to Medicare in 2006), you must actively choose and join a Part D drug plan in your area. Medicare offers these different types of coverage so that you can choose which ones you want, according to your individual circumstances.
Here are points to consider in different situations:
• You can delay enrollment in Part B (which covers doctors’ services, outpatient care and medical equipment) after age 65, without adverse consequences, for as long as you receive primary health care from an employer for which you or your spouse actively works.
• If you receive Social Security benefits at the time you turn 65, or apply for them at a later date, the Social Security Administration (which handles
Medicare enrollment) will automatically enroll you in both Part A and Part B and send your Medicare ID card through the mail. But (if you have primary insurance from a current employer, as described above) you can decline Part B, following the instructions that Social Security includes in its letter that accompanies your card and meeting the deadline.
• If you work for an employer that offers health insurance in the form of a high-deductible plan paired with a health savings account (HSA), be aware that under IRS rules you can not contribute to an HSA in any month that you are enrolled in any part of Medicare. (If you do, you’ll pay tax on the contributions at the end of the tax year.) If you wish to continue contributing to your account, you need to delay enrollment in Part A as well as Part B. Note that you can not delay or opt out of Part A if you receive any Social Security benefits (retirement, disability or spousal).
• You do not need Part D prescription drug coverage if you have “creditable” coverage from elsewhere– such as from a current or former employer, COBRA, the federal employees health benefits (FEHB) program, the military’s TRICARE programs, the Veterans Affairs health system, or individual health insurance you’ve purchased yourself. “Creditable” coverage means that Medicare considers it to be of equal or better value than Part D.
• If you receive your coverage from Medicaid, the state-run system that provides health insurance to people with incomes under a certain level, this becomes secondary insurance when you become eligible for Medicare. Medicare will settle your Part A and Part B medical bills first and Medicaid will pay for any services that it covers but Medicare doesn’t– plus your premiums, deductibles and copays. You also automatically qualify for full Extra Help, a program that provides Medicare Part D drug coverage at low or reduced cost, but you must actively join a Part D drug plan to get this coverage and pay small copays for your prescriptions.