Medicare Advantage

What is a Medicare Advantage Plan?

Medicare Advantage Plans cover benefits from Original Medicare Part A (hospital insurance), Part B (medical insurance), usually Part D (prescription drug coverage), and sometimes additional benefits that Original Medicare doesn’t cover. Each Medicare Advantage Plan insurer sets the rules about how you receive and pay for these benefits.

Medicare Advantage Plan Benefits 

Hospital and skilled nursing facility inpatient care

Home health care

Prescription drug coverage (if included in plan)

Medically necessary outpatient services, such as:

  • Doctor’s visits
  • Ambulance services
  • Emergency and urgent care
  • Durable medical equipment (DME)
  • Mental health care
  • Prescription drugs that you cannot self-administer
  • X-rays
  • Laboratory tests

Preventive services, such as:

  • Vaccinations
  • Cancer screenings
  • Diabetes screenings
  • Depression screenings

Additional benefits (depending on your plan), such as:

  • Routine vision exams with allowance for glasses
  • Routine dental exams
  • Hearing exams with allowance for hearing aids
  • Fitness and wellness programs and discounts
  • Transportation to medically necessary care
  • Over-the-counter (OTC) drugs


Types of Medicare Advantage plans

  • Health Maintenance Organizations (HMOs)
  • Preferred Provider Organizations (PPOs)
  • Special Needs Plans (SNPSs)
  • Medicare Medical Savings Accounts (MSAs)
  • Private Fee-for-Service Plans (PFFS)

Original Medicare

Medicare Advantage

Enrollees can go to any doctor or hospital that takes Medicare, anywhere in the U.S.

In many cases, enrollees can only use doctors and other providers who are in the plan’s network and service area (for non-emergency care).

In most cases enrollees don’t need a referral to see a specialist.

Those enrolled may need to get a referral to see a specialist.

For Part B-covered services, enrollees usually pay 20% of the Medicare-approved amount after you meet your deductible. This amount is called coinsurance.

Out-of-pocket costs vary – plans may have lower or higher out-of-pocket costs for certain services. Enrollees may also have an additional premium.

Enrollees pay a premium (monthly payment) for Part B. If they choose to join a Medicare drug plan,  those enrolled pay a separate premium for Medicare drug coverage (Part D).

Enrollees pay the monthly Part B premium and may also have to pay the plan’s premium. Some plans may have a $0 premium and may help pay all or part of the Part B premium. Most plans include Medicare drug coverage (Part D).

There’s no yearly limit on what is paid out-of-pocket, unless the enrollee has supplemental coverage – like Medicare Supplement Insurance (Medigap).

Plans have a yearly limit on what is paid out of pocket for services Medicare Part A and Part B cover. Once the plan’s limit, is reached enrollees pay nothing for services Part A and Part B covers for the rest of the year.

Those enrolled can choose to buy Medigap to help pay  remaining out-of-pocket costs (like your 20% coinsurance). Or, they can use coverage from a former employer or union, or Medicaid.

Enrollees can’t buy and don’t need Medigap.

Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Original Medicare doesn’t cover some benefits like eye exams, most dental care, and routine exams.

Plans must cover all medically necessary services that Original Medicare covers. Plans may also offer some extra benefits that Original Medicare doesn't cover - like certain vision, hearing, and dental services.

Enrollees can join a separate Medicare drug plan to get Medicare drug coverage (Part D).

Medicare drug coverage (Part D) is included in most plans. In most types of Medicare Advantage Plans, those enrolled can't join a separate Medicare drug plan.

In most cases, enrollees don’t need approval for Original Medicare to cover your services or supplies

In many cases, enrollees may need to get approval from their plan before it covers certain services or supplies.

Original Medicare generally doesn’t cover medical care outside the U.S. Enrollees may be able to buy a Medicare Supplement Insurance (Medigap) policy that covers emergency care outside the U.S.

Plans generally don’t cover medical care outside the U.S. Some plans may offer a supplemental benefit that covers emergency and urgently needed services when traveling outside the U.S.


What is The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program?

The Centers for Medicare & Medicaid Services (CMS) awards incentive payments to skilled nursing facilities (SNFs) through the SNF VBP Program to encourage SNFs to improve the quality of care they provide to patients. For the Fiscal Year (FY) 2024 Program year, performance in the SNF VBP Program is based on a single measure of all-cause hospital readmissions.

In Section 215 of the Protecting Access to Medicare Act of 2014 (PAMA), Congress added Sections 1888(g) and (h) to the Social Security Act, which required the Secretary of the Department of Health and Human Services (HHS) to establish a SNF VBP Program. CMS began applying incentive payments for SNFs on October 1, 2018.

PAMA specifies that under the SNF VBP Program, SNFs:

  • Are evaluated by their performance on a hospital readmission measure;
  • Are assessed on both improvement and achievement, and scored on the higher of the two;
  • Receive quarterly confidential feedback reports containing information about their performance; and
  • Earn incentive payments based on their performance.

All SNFs paid under Medicare’s SNF Prospective Payment System (PPS) are subject to the SNF VBP Program. Inclusion in the SNF VBP Program does not require any action on the part of SNFs.

Medicare Advantage Plans in Iowa

  • In 2023, there are 70 Medicare Advantage Plans available in Iowa.
  • 96.7% of the total Medicare population in Iowa has access to a Medicare Advantage Plan with a $0 monthly premium in 2023.
  • In 2023, the average monthly premium for a Medicare Advantage Plan in Iowa is $9.13, a decrease from $9.37 in 2022.
  • Eleven Medicare Advantage Plans offer innovative benefits, such as wellness and health care planning, reduced cost-sharing, and rewards and incentives programs in 2023.