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Six things you must know about your Medicare Advantage Plan

Kathleen Blanchard's picture
Taking charge of your health means knowing what your Medicare Advantage plan covers

What don’t you know about your own Medicare supplement that can end up costing you or helping you in the long-run? Here are six things you need to know about your Medicare Advantage health plan that surprisingly few people take time to explore.


It is surprising how many Medicare Advantage plan members know little about their health insurance coverage and benefits. Taking time to explore what your plan includes or doesn't include can help you prepare ahead of time for unforeseen events.

Prescription deductibles

Have you looked at your prescription drug plan closely? If not, you may be under the false impression that your medications are higher cost than normal, especially if you had chosen a new Medicare supplement this year.

Many plans do not start paying for prescriptions until a deductible is met, but surprisingly a significant portion of health insurance plan enrollees don't know their drug plan details.

If you do have a deductible, also known as stage 1 of your prescription plan, your medications will revert to a lower cost co-payment after the deductible is met.

Where to go when you need help with medication cost

What you need to know if you are on high cost medications is when to ask for help. Diabetics, for instance, can obtain assistance for some types of insulin once they reach the Medicare coverage gap, also known as the “donut hole”.

Some medications are available if you are in the Medicare coverage gap and others can be obtained even if you have Medicare drug coverage. A resource for finding where to get help with medications is needymeds.org.

Many insurance plans offer a medication review annually that is a consult with a pharmacist. Asking for your annual review can help guide you to lower cost medication option that you can discuss with your doctor.

You should read your summary from your insurance company that tracks total drug spending throughout the year so you’re not taken off guard at the pharmacy.

If you know you’re approaching the donut hole you can remain proactive to avoid missing taking needed medications. You can call customer service on the back of your insurance ID card and ask to speak with a nurse case manager or pharmacy benefit manager to get started. Your doctor can also help with applications for medication assistance that often have generous income allowances for getting medications either free or for low cost.

This year Medicare recipients reach the coverage gap when spending on medications, including your deductible, reaches $2,960 on covered drugs. It’s important to understand that the donut hole occurs based on total amount spent on medications, between you and your insurer; not just what you pay out of pocket.

If you are on medications for diabetes, COPD or other chronic illnesses that are associated with a high co-payment, you are at greater risk of reaching the coverage gap that will disappear by 2020 thanks to the Affordable Health Care Act.
This year, Medicare will pay 35 percent of the cost of covered generic drugs if you reach the coverage gap.

Eye and dental benefits

If you have been skipping your eye exam and visit to the dentist you will want to make sure you’re not missing out on a covered benefit that might be part of your medical insurance plan.

Many Medicare Advantage plans have extra “riders” that might include eye and dental care discounts or zero co-payment exams through participating providers. Medicare covers annual dental cleaning, bitewing X-rays and oral exams.

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Advantage plans could also include low co-payments if you need a filling or a tooth extraction, making it worthwhile to know all you can about your Medicare supplement health insurance coverage.

Free over-the-counter items

Your Medicare Advantage plan might also offer free over-the-counter products that include Band-Aids, glucose tablets, elastic bandages, vitamins, cough and cold remedies, cotton swabs, alcohol pads, antihistamines and more, none of which are covered by Medicare part B.

Stay healthy, get healthy programs

You should check your health insurance plan for any programs, education materials and even no-cost gym memberships that can help you remain healthy.

Included in many plans are telephonic case managers, social workers, coaches, counselors for depression, stress, weight loss, smoking cessation, and even pain management. Your insurance plan administrator may even be trying to contact you to set up an in-home visit from a nurse practitioner or doctor to help coordinate your care and health care needs.


Taking time to read your co-payment responsibility for tests, doctor and physician specialists, hospital stays and therapy can help you prepare for an unplanned adverse health event.

If your insurance plan offers the option, you may want to consider a Medicare Savings Plan, also known as an MSA that can be used for covered health expenses.

Medicare Advantage plans offered with a MSA are high deductible and receive extra funding from Medicare to help you pay for your healthcare costs. Once you have met your deductible you may be responsible for low copayments. After you receive your money from Medicare you can place it in a savings account where you will be responsible for tracking withdrawals and reporting of your spending each year.

Some Medicare Advantage plans have in an out of network benefits. Before you consent to out of network care such as out- patient surgery, doctor visit or lab work, make sure your health care provider agrees to accept what your plan will pay. Otherwise you find yourself paying more for your health care.

Check your plan to find out where you can go for x-rays, blood work and outpatient tests for zero co-pay. Cost sharing varies depending on whether you go to a hospital, doctor’s office or free standing facility. Some plans have no co-payment for lab work at facilities such as Quest or LabCorp that makes knowing where you can go in your area worthwhile.


The result of not understanding your health insurance plan can lead to frustration, financial hardship, inability to get the care you need and all too often it can make consumers angry when they find out they have to pay out-of-pocket for health care or have limited medication prescription benefits.

The takeaway is that few people seem to really know what is covered by their Medicare Advantage plan, their cost sharing responsibility and what resources might be readily available with their health insurance coverage.

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