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Medicare MSP Compliance

Understanding Medicare Advantage Plans: A Comprehensive Overview

June 9, 2023


Medicare Advantage plans have emerged as a popular option for individuals seeking comprehensive healthcare coverage beyond what traditional Medicare (Part A/B) offers. These plans, also known as Medicare Part C, provide a unique alternative to traditional fee-for-service Medicare by combining various medical services into a single, all-inclusive package. In this article, we will provide a high-level overview of Medicare Advantage plans, helping you understand the key aspects and benefits they offer.

What is a Medicare Advantage Plan?

Medicare Advantage plans are private health insurance options offered by Medicare-approved insurance companies. They work by bundling together the benefits of Medicare Part A (hospital insurance) and Part B (medical insurance) into a single plan. In addition, most Medicare Advantage plans often include prescription drug coverage (Part D) as well. These plans are required to provide at least the same level of coverage as Original Medicare, but many go beyond by offering additional benefits such as dental, vision, hearing, and fitness programs.

Coverage and Benefits:

Medicare Advantage plans typically provide coverage through a network of healthcare providers, including doctors, hospitals, and specialists. There are different types of Medicare Advantage plans, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Special Needs Plans (SNPs). Each type has its own network rules and coverage options. Some plans may require you to get referrals from a primary care physician before seeing a specialist, while others offer more flexibility to see out-of-network providers at a higher cost.

Costs and Enrollment:

Enrolling in a Medicare Advantage plan requires individuals to be eligible for Medicare Part A and Part B. While Original Medicare has standardized premiums, Medicare Advantage plans often have their own premiums, deductibles, and cost-sharing arrangements. Some plans have low or even $0 premiums, but you still need to pay your Part B premium. It’s crucial to review and compare the costs and coverage details of different plans to find the best fit for your healthcare needs and budget.

Additional Considerations:

When considering a Medicare Advantage plan, it’s important to understand that these plans have certain limitations. For instance, they have specific enrollment periods and geographical limitations. Moreover, Medicare Advantage plans may require prior authorization for certain procedures or medications. It’s essential to carefully review the plan’s rules and restrictions before making a decision.

Personal Injuries & Medicare Advantage

Medicare Advantage plans enjoy the same rights as traditional Medicare does under the Medicare Secondary Payer Act (MSP) when a personal injury settlement occurs, and the Advantage plan makes payments for injury-related care.  The Advantage plan will have a lien. Pursuant to the MSP, their repayment formulas are the same as Medicare under 411.37 (c) and (d) which only requires a procurement cost reduction.  The key for personal injury victims is making sure you discover all Medicare claims since Medicare itself doesn’t alert you to an Advantage plan lien.  Failing to reimburse a Medicare Advantage plan could expose the parties to a claim of double the lien amount.  In addition, Medicare Set-Aside considerations may need to be addressed since it is always possible to switch back to traditional Medicare under Part A/B.  Avoiding a denial of future injury-related care is always a prudent course of action by exploring the Medicare Set-Aside issue. 


Medicare Advantage plans offer an alternative approach to healthcare coverage by combining the benefits of Original Medicare with additional services and potentially lower out-of-pocket costs. By understanding the basics of these plans, you can make an informed decision about your healthcare needs. Remember to review the available plans, compare their coverage and costs, and consult with a licensed insurance professional or Medicare counselor to ensure the plan aligns with your specific requirements.  It is also important that if you get injured while being covered by an Advantage plan that you understand the implications of a settlement in terms of reimbursement of the plan as well as future eligibility. 

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