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What is a Medicare Replacement Plan


It is not uncommon to hear the term Medicare replacement plan. Usually, people use this phrase to refer to Medicare Advantage plans.

Advantage plans are thought to replace Original Medicare because they step in place of Part A and Part B as your primary source of coverage. However, it is not that simple. If you’re thinking about signing up for an Advantage plan, we’re here to explain how they got this name.

How Does a Medicare Replacement Plan Work?

Advantage, or Part C – often coined replacement plans – stand in place of your Medicare for 12 months. They don’t act as a permanent replacement, and you can always return to Original Medicare during the Medicare Advantage Open Enrollment Period or Annual Enrollment Period.

These plans provide benefits through a private insurance company rather than through Medicare. Once enrolled, you must use the plan’s network of providers and hospitals to be covered. To be eligible for an Advantage plan, you must enroll in Part A and Part B of Medicare.

Does a Medicare Advantage Plan Replace Medicare?

To be clear, an Advantage plan does not technically replace Medicare. However, it acts as your primary coverage. Medicare pays private insurance companies offering Advantage plans to handle beneficiary claims and benefits on their behalf.

The Advantage plan must offer the same benefits as Parts A and B and often provides additional services and perks. These include coverage for prescription drugs, dental, vision, and hearing plans, free gym memberships, and more. Benefits vary depending on plan and carrier.

If you enroll in an Advantage plan, be sure to review your Summary of Benefits. This document will let you know what’s not covered, as well as list copay amounts, deductibles, and premiums for which you’ll be responsible.

Additionally, your benefits are subject to change each year. As an Advantage enrollee, you’ll want to keep your eyes out for your Annual Notice of Change letter to make sure you’re still happy with your plan. You should expect to get this letter in September, right before the Annual Enrollment Period.

Suppose you are unhappy with the changes to your plan. In that case, the Annual Enrollment Period allows you to make any necessary changes to your plan that will go into effect on January 1 of the following year.

What is the Best Medicare Advantage Plan?

The best Advantage plan for you depends on your needs. Furthermore, it depends on if you would benefit from enrolling in an Advantage plan at all. When deciding, consider how the downsides to Medicare Advantage plans would affect you.

Some find Advantage plan networks restrictive and often pay more than they save in out-of-network copays. On the other hand, those who don’t need to visit many doctors enjoy having one plan for all their needs and spending less than they would for a Medigap plan.

If you’re considering enrolling in an Advantage plan, be sure to go with a top-rated carrier. Also, ensure that you’re familiar with how the plan you’ve chosen works.

FAQs

Is a Medicare Advantage plan the same as a Medicare replacement plan?
Yes – replacement plan is just another way of saying Advantage plan.
Can I switch from a Medicare Advantage plan back to Original Medicare?
Yes – each year, you have two opportunities to switch from an Advantage plan. The Medicare Advantage Open Enrollment Period (January 1 through March 31) and the Annual Enrollment Period (October 15 through December 7).
Can a Medicare Advantage plan drop you?
If you don’t pay the premium for your policy or your Part B premium, your Advantage plan can drop you. Likewise, if you move outside the service area, they can drop you. Otherwise, your plan will typically auto-renew.

How to Get Help Understanding Medicare Replacement Plans

To review your options and decide whether a Medicare Advantage plan is best for you, our licensed agents are here to help! You can get in contact with one of our Medicare experts today by completing our online rate comparison form or by calling the number above to receive rates and information in your area.

Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

18 thoughts on “What is a Medicare Replacement Plan

    1. Tommi, it is possible to have Tricare for Life as a secondary to Medicare Advantage, however it is important to check with your Tricare administrators to be sure the plan you want to enroll in works with your Tricare Plan and that your doctors are in the plans network.

  1. My mother has a Medicare Advantage PPO plan. She is paying UHC and Medicare. Why would she be paying for both?

    1. Hi Celine! In order to enroll in either a Medicare Advantage plan or Medigap plan, you must be enrolled in Part B.

  2. I am writing for my Uncle, He has a platinum blue plan in MN (medicare replacement) He had gotten a shot that was experimental for CA and medicare denied, he was not sure he signed an ABN. If that goes to his medicare replacement plan and he has an ABN signed, is he responsible for that cost or does the other insurance have to write it off since it is a replacement plan. His medicare EOB says he is not responsible, so it should be written off. But my understanding is that if a replacement plan is billed that they follow medicare guidelines and pt is not responsible for that.

  3. How can we know if a patient actually has Medicare & not a replacement plan? Many patients call our office claiming they have Medicare when in fact they have a replacement plan which ends up not covering them fully.

    1. Hi Melissa! This is a great question, the issue is very common. Since a lot of beneficiaries don’t really understand what coverage they have, unfortunately, it’s up to the staff to ask the right leading questions. A great leading question is if their plan includes extra services like dental, vision, & hearing. If they say yes, then that’s a red flag that the plan is a replacement plan. Another good leading question is if they have a network. If the answer is yes, that’s another red flag. The staff needs to be educated on the differences between Medicare and Medicare Advantage so they can better vet patients before coming in. The only way around that is to call Medicare directly when the patient is checking in at the front desk. Medicare will only speak to you if the patient is there.

  4. If a patient has a Medicare Advantage plan and is in a Swingbed for 10 days. we have to file a shadow claim to Medicare to let them know. Do those days count against the Medicare days if the patient switches back to traditional Medicare

    1. Hi Christie. I believe so if it’s within the same benefit period or calendar year. However, this is tricky. I would contact Medicare directly to confirm.

  5. My brother-in-law is on a Medicare advantage plan and he now needs to go into short term skilled nursing them transition him to long term care through Medicaid I am having trouble getting him into a facility because they are using his secondary insurance first is that correct. Should he sign up for straight Medicare?

  6. With a Medicare replacement plan will it pay for a women’s yearly exam, every year or every other year? Do you have to use preventive cpt codes per age group or only use the G and Q codes accordingly. Thank you, Beth

    1. Hi Beth! Medicare Replacement plans must provide coverage for the same services as Original Medicare. An annual pap smear is covered every 24 months or every 12 months for women at high risk. Unfortunately, I’m not familiar with cpt codes since we do not bill Medicare. You may be able to find the correct cpt codes here.

  7. I am 66yrs old woman and have a pacemaker and I also have diabetes. I take Eliquis 5mg, Synthroid 75mcg, Mirapex 4.5mg, Glimepiride 1mg mg, glyxamb25mg-5mg, Potassium 10mg 3 daily ,Pantoprazole Sodium DR 40mg, , Gabapentin 300mg, Lantus insulin, I take 40units , Repatha Sureclick, 140units, Sotalol 80mg. I have been trying to find an insurance that will cover my medicine and health care needs so my husband can retire but so far I haven’t found one that will work . Most want more out of pocket prices than my $890.00 I get from Social Security. My husband of 48 years has good insurance that has only a 20% co-pay. Do you know of any way to get me insurance that will let me get the medicines that I need without taking every penny I get and let my husband retire.

    1. Without speaking to you over the phone to go over the specifics, it’s hard to determine what plan would work for you. When looking at GoodRx, all the medications you listed are covered. Only two of them say 50% of plans will cover the medication. I would recommend using the Medicare plan finder tool. It will let you input all your medications and then see what plans cover them and how much your out of pocket costs will be. You will want to look at both Medicare Advantage plans and Part D.

  8. My 42 y/o so is a Type I diabetic. He is in desperate need of a continuous glucose monitor due to critically sporadic low blood sugars. He is covered on his wife’s health plan at work. His secondary is Medicare. His wife’s Cigna’s said they will cover only 20% of the cgm cost, and that’s only after he reaches his yearly $7500 deductible. Medicare wont cover it because he has a primary insurance. Would an Advantage plan cover the costs associated wit this monitor and monthly sensors? Thank you, Lynne

    1. Hi Lynne! Thank you for your question! Medicare Advantage plan benefits are decided by the carrier, so what you pay out of pocket for each service will be different for each carrier. For example, you could pay $100 out of pocket with Cigna for a CGM, but you may only pay $20 out of pocket with another carrier for the same CGM. The only way around this is if you make Medicare his primary coverage, assuming his employer has more than 20 employees. If you make his Medicare coverage primary, you shouldn’t have that deductible to meet. I would suggest speaking to his benefits administrator to see what all his options are and to make sure his employer coverage is considered creditable under Medicare. I hope this helps!

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