How is Medicare Advantage plan funded?

Last Updated : 09/15/20184 min read

Medicare Advantage (Medicare Part C) is an alternative way to get your benefits under Original Medicare (Part A and Part B). By law, Medicare Advantage plans must cover everything that is covered under Original Medicare, except for hospice care, which is still covered by Original Medicare Part A. Some Medicare Advantage plans offer additional benefits such as routine dental and routine vision care.

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According to 2016 data from the Kaiser Family Foundation, about one in three Medicare beneficiaries are enrolled in a Medicare Advantage plan, or about 17.6 million individuals. This article explains how Medicare funding works with Medicare Advantage plans.

How is Medicare funded?

The Medicare program was established in 1965 and it set up two separate Medicare trust funds to cover program expenses:

  • The Medicare Hospital Insurance, or HI Trust Fund gets money primarily from payroll taxes. It gets much smaller amounts from income tax on Social Security benefits and Medicare Part A premiums paid by those who don’t qualify for premium-free Part A. The money in this trust fund pays for Part A expenses such as inpatient hospital care, skilled nursing facility care, and hospice.
  • The Medicare Supplemental Medical Insurance, or SMI Trust Fund gets its Medicare funding primarily from money Congress allocates for the program and from Part B premiums and Medicare Part D Prescription Drug Plan premiums. This fund pays for outpatient health care, durable medical equipment, certain preventative services and prescription drugs.

The Medicare funding sources are the same whether you are enrolled in Original Medicare or a Medicare Advantage plan.

How are benefits paid under Medicare Advantage?

Medicare Advantage plans are offered by private insurance companies contracted with Medicare to provide program benefits. Under Medicare Advantage, the insurance company receives a set amount of money each year per enrollee to cover health care expenses for the year. The amount is usually exactly the same for each enrollee and it doesn’t increase or decrease depending on the individual’s actual medical costs.

In addition to the Part B premium, which you must continue to pay when you enroll in Medicare Advantage, some Medicare Advantage plans also charge a separate monthly premium.

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The insurance company uses this pool of money from the Medicare Trust Funds plus any additional premiums paid by plan members to pay the covered health care expenses for everyone enrolled in a particular plan. Claims for people enrolled in Medicare Advantage are paid by the insurance company and not by the Medicare program as they are for those enrolled in Original Medicare.

Because the insurance companies have a set amount of Medicare funding each year to cover all of their members’ health care expenses, they often have special rules and requirements to help keep costs down. Many plans require you to get care from network providers or get prior authorization for any expensive tests and procedures.

In return, however, Medicare Advantage plans tend to have lower out-of-pocket costs than Original Medicare, and unlike Original Medicare, Medicare Advantage plans also have annual limits on what you have to pay out-of-pocket before the plan covers all your costs. Many Medicare Advantage plans also include Part D coverage for prescription drugs so you can get all your Medicare benefits in one convenient plan.

Do all private insurance companies have the same Medicare Advantage plans?

Although the Medicare funding is the same for all insurance companies offering Medicare Advantage plans, each company chooses what types of plans and benefits it will offer. No matter what company and plan type you select, however, you are still entitled to all the same rights and protections you have under Original Medicare.

It’s important to note that plan premiums may also vary depending on the plan you select and where you live. You may be able to enroll in a zero-premium Medicare Advantage plan (although, remember, you still have to pay your regular Part B premium) and you may have other costs, such as copayments and coinsurance.

Need more information on Medicare Advantage plans?

I am happy to answer your questions about Medicare Advantage. If you prefer, you can schedule a phone call or request an email by clicking on the buttons below. You can also find out about plan options in your area by clicking the Compare Plans button.

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