What Does Medicare Advantage Cover in Pennsylvania?
Federal law requires every Medicare Advantage plan to cover the services offered by Original Medicare, also called Medicare Part A and Medicare Part B. Usually, however, Medicare Advantage covers more than Original Medicare, including prescription drug benefits, eyeglasses, hearing aids, and dental visits, plus coverage for health and wellness programs.
You can use our plan comparison page to find plans in your area of Pennsylvania and learn about exactly what each plan covers.
Typical Medicare Advantage Benefits
Here’s a list of what’s covered by a typical Medicare Advantage plan:
- Doctor visits. For full coverage, Medicare Advantage Plans require you to use providers in their network. Most plans charge a small copayment for doctor and specialist visits.
- Outpatient services. Most plans charge a copayment and then cover all costs of services like x-rays, lab tests, and outpatient surgery.
- Hospital stays. You must use network providers. Most plans charge a copayment but otherwise cover the full cost of inpatient hospital care.
- Ambulance services. Most plans charge a copayment every time you use an ambulance but otherwise cover all costs.
- Emergency room services. Most plans charge a copayment for every emergency room visit but otherwise cover all costs.
- Urgent care. Urgent care is for non-life-threatening medical needs that must be handled promptly. Most plans charge a copayment for these services but otherwise cover all costs.
- Home health care. Plans usually offer the same benefits as Original Medicare.
- Durable medical equipment. Like Original Medicare, a Medicare Advantage plan typically pays for 80% of items such as a wheelchair, walker, or hospital bed. Your share is usually 20%.
- Skilled nursing facilities. Most plans charge a copayment but cover all costs up to 100 days.
- Hospice care. Hospice benefits are provided under Original Medicare, even for those with Medicare Advantage plans. For details about hospice benefits, see the Medicare Rights Center.)
- Mental health care facilities. Most plans charge a copayment but cover all costs up to 190 days.
- Preventive services. As long as you see network providers, a Medicare Advantage plan can’t charge you for preventive services covered by Original Medicare, such as routine checkups, flu shots, and screenings for conditions like prostate or breast cancer.
- Supplemental benefits. You should do some research to determine the extent of coverage for services not covered by Original Medicare—for example, vision, dental, chiropractic, acupuncture, health club memberships, and non-emergency transportation services for medical care.
- Prescription drug coverage. Similarly, a Medicare Advantage plan may offer prescription drug coverage (Medicare Part D). These plans are often called MAPDs. Contact the plan provider to find out whether your drugs are covered and what your copay will be.
Medicare Special Needs Plans
In addition to the basic plans described above, some Medicare Advantage plans are designed for individuals with special needs. These plans restrict membership to people with specific conditions. They tailor their benefits, provider choices, and drug coverage to meet the needs of the groups they serve. A Special Needs Plan (SNP) may serve one or more of the following communities:
- people who have a chronic, severe, or disabling condition defined by the plan—for example, diabetes, heart disease, or HIV/AIDS, or end-stage renal disease (ESRD)
- people who are eligible for both Medicare and Medicaid
- people who live in a nursing home or special care facility for the intellectually disabled, or who require nursing care at home
To learn more, see Frequently Asked Questions About Special Needs Plans at Medicare.gov. You can use our plan comparison page to search for SNPs in your area.
How to Find Out If Your Medicare Advantage Plan Covers What You Need
A Medicare Advantage plan can choose not to cover the costs of services that aren’t considered medically necessary under Medicare. If you have questions about whether a service is covered, check with your plan provider before you get the service. If your provider says the service isn’t medically necessary, you’ll probably have to pay all the costs, but you can appeal the decision if you feel the service should have been covered.
You may always ask your plan for a written advance coverage decision to confirm that the treatment will be covered. This may be useful if the plan later balks at paying for the service.
You may also be interested in:
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Learn how to sign up for a Medicare Advantage plan, including when you can enroll and when you may have to wait.
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