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Medicare Advantage (Medicare Part C, MA) is a capitated program for providing Medicare benefits in the United States. Under Part C, Medicare pays a sponsor a fixed payment. The sponsor then pays for the health care expenses of enrollees. Sponsors are allowed to vary the benefits from those provided by Medicare's Parts A and B as long as they provide the actuarial equivalent of those programs.: 61 The sponsors vary from primarily integrated health delivery systems to unions to other types of non profit charities to insurance companies. The largest sponsor is a hybrid: the non profit charity AARP using UnitedHealth.
Part C plans are required to offer coverage that meets or exceeds the standards set by Medicare Parts A and B, but they do not have to cover every benefit in the same way (actuarial equivalence is required). The major advantage of a public Part C Medicare Advantage plan is that each features an out of pocket annual spend limit of the beneficiary's choosing, typically ranging from $1500 to about $8000 in 2023. The lower the limit the higher the premium as with insurance of all types. Many Part C plans with a high limit have no premium (but the Part C enrollee still has to pay a Part B premium if otherwise required). Original Medicare Parts A and B do not include such out of pocket spend limit protection.
Plans must be approved by the Centers for Medicare and Medicaid Services (CMS). If a MA plan changes some benefits, the savings must be passed along to consumers by lowering co-payments for doctor visits (or any other plus or minus aggregation approved by CMS). Coverage must include inpatient hospital (Part A) and outpatient (Part B) services. Typically, the plan also includes prescription drug (Part D) coverage. Many plans also offer additional benefits, such as hearing or dental coverage or vision services not covered by Part B of Medicare. Such plans typically require a higher premium.: 62
Those who do not enroll in a Part C plan receive coverage for Part A and Part B services. Many purchase private supplemental coverage (Medigap) to cover the large co-pays, co-insurance and deductibles in Original Medicare Parts A and B, and enroll separately in Part D for coverage of prescription drugs.: 8 Public Part C Medicare Advantage plans also include nominal co-pays and co-insurance but there are no deductibles
Original Medicare and Medicare Advantage pay healthcare providers differently. Original Medicare typically reimburses healthcare providers with a fee for each service. This fee is often calculated with a standard formula (for example, the prospective payment system for hospital services). Providers either accept Medicare's reimbursement rates or opt out of the program. Public Medicare Advantage plans negotiate payment rates and form networks with healthcare providers, similar to private health insurance plans that almost all Americans not of Medicare age use.
As of 2023, about 50% of Medicare beneficiaries were members of Medicare Advantage plans. Nearly all Medicare beneficiaries have access to at least one Medicare Advantage plan; on average 39 plans per county were available. By design, the cost to the trust funds of Medicare Advantage plan members and those beneficiaries receiving services on a fee basis should be the same by county. However the convoluted framework/bid/rebate process built into the 2003 and 2010 revisions to the 1997 Medicare Advantage law means this one-one relationship will always be out of synch. On average, over the 25 years of the program comparable people on both programs (that is, for example, people not on Medicaid or Federal retirees or people still working or in the VA system or in union plans) have costs the Trust Funds equal amounts .
Other plan types, such as 1876 Cost plans, are available in some areas. Cost plans are not Medicare Advantage plans and are not capitated. Instead, beneficiaries keep their Original Medicare benefits while the plan sponsor administers their Part A and Part B benefits.
Medicare + Medicaid
Some MA plans cover both Medicare and Medicaid services for people who are eligible for both. To be eligible both Medicare and Medicaid coverage, often referred to as "dual eligibility," individuals must meet specific eligibility criteria for each program separately. Medicare is typically available to those aged 65 and older, certain individuals with disabilities, and those with end-stage renal disease or ALS. Medicaid eligibility is income and asset-based, varying by state, and is generally available to low-income individuals.
Value-based Insurance Design
The CMS Innovation Center's Medicare Advantage Value-Based Insurance Design (VBID) model tests the effect of offering customized benefits that are designed to better manage their disease(s) and address social needs, including food insecurity and social isolation. The VBID Hospice Benefit Component provides access to palliative/hospice services.
The number of people using public Part C of Medicare grew from almost zero since 1998 to 26.5 million in 2021. The top-25 Medicare Advantage insurers enroll a combined 21.6 million people, or 87 percent of the total. Nine plans saw growth over 10% in 2021.
In 2022, 295 plans (up from 256 in 2021) covered all Medicare services, plus Medicaid-covered behavioral health treatment or long term services and support.
In 2022, 1000 MA plans were projected to enroll 3.7 million people in VBID. The hospice benefit will be offered by 115 Medicare Advantage plans in 22 states and territories.
In 2019, Medicare Advantage Organizations denied 13% of prior authorization requests that would have been accepted if the beneficiaries were in original Medicare. In 2019 alone, Medicare Advantage plans cost tax-payers $9 billion more dollars than if beneficiaries were in original Medicare. This is due to a financial incentive for physicians associated with these plans to manipulate diagnosis codes. In addition, while original Medicare allows for beneficiaries to visit any provider that accepts Medicare, most Medicare Advantage plans restrict the number of providers and hospitals that beneficiaries can visit.
As a result of labeling beneficiaries with more severe diagnoses as a way to generate profit, many companies that participate in MA plans such as UnitedHealth, Humana, Elevance, and Kaiser have or are facing federal fraud lawsuits from the Department of Justice.
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Medicare Advantage plans are generally required to offer at least one plan that covers the Part D drug benefit. The typical reasons for not choosing a Part C plan with Part D integrated is if a beneficiary receives drug coverage from the VA or a former employer. In 2023, about 90% of Medicare Advantage plans offer prescription drug coverage, while most Medicare Advantage enrollees (88%) select this benefit.
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- CMS official web site
- Legal Issues Relating to the Secretary’s Authority to Set Payment Rates Under the Medicare Advantage Program Congressional Research Service
- Medicare.gov — the official website for people with Medicare
- As codified in 42 U.S.C. chapter 7 of the United States Code from the LII
- As codified in 42 U.S.C. chapter 7 of the United States Code from the US House of Representatives
- Medicare & Medicaid Resources — Medicare information site
- Kaiser Family Foundation — Wide range of free information about the Medicare program and other U.S. health issues including state-level data on health care spending and utilization, including MedicareMedicare Advantage in 2022: Enrollment Update and Key Trends.
- Medicare – Alliance for Health Reform The nonpartisan, nonprofit Alliance for Health Reform offers information about health reform, in a number of formats, to elected officials and their staffs, journalists, policy analysts and advocates.
- Social Security and Disability News Resource Center
- How Stuff Works – Medicare
- Medicare Policy Center