November 2019: Medicare Advantage Supplemental Benefits Copy

What are Medicare Advantage Supplemental Benefits?

A supplemental benefit is an item or service covered by a Medicare Advantage Plan that is not covered by Original Medicare. These benefits do not need to be provided by Medicare providers or at Medicare-certified facilities. Instead, to receive these items or services, you need to follow your plan’s rules. Some commonly offered supplemental benefits are dental care, vision care, hearing aides, and gym membership.

Supplemental benefits must, with some exceptions (see below), be primarily health-related. These benefits can either be:

  • Optional, meaning that they are offered to everyone who is enrolled in a plan, and you can choose to purchase coverage if you want to, or
  • Mandatory, meaning that they are covered for everyone enrolled in a Medicare Advantage Plan and you cannot decline the coverage (even if you do not need to use the service).

Changes to supplemental benefits in 2020

Beginning in 2020, Medicare Advantage Plans can begin covering supplemental benefits that are not primarily health-related for beneficiaries who have chronic illnesses. These benefits should address social determinants of health. A social determinant of health is part of your life that can affect your health in some way, such as not having access to transportation. Plans can now offer benefits like meal delivery, transportation for non-medical needs, and home air cleaners. In order to be eligible for this benefits, you must be chronically ill. This means that you:

  • Have at least one medically complex condition that is life-threatening or significantly limits your health or function
  • Have a high risk of hospitalization or other negative health outcomes, and
  • Require intensive care coordination

Since Medicare Advantage Plans will be able to create sets of supplemental benefits for people with specific chronic illnesses, not every member of a Medicare Advantage Plan will have access to the same set of benefits. For example, a plan might cover services like home air cleaning and carpet shampooing for members with severe asthma. A member of that plan who has severe asthma will be able to get that service covered, while a member who does not have asthma, or whose asthma is mild, will not.

Questions to ask about supplemental benefits

Before signing up for a Medicare Advantage Plan that includes supplemental benefits or before receiving services that are covered by these benefits, ask these questions to better understand the available coverage:

  • Is this definitely a supplemental benefit, or is this service covered under Original Medicare?
    • Sometimes, plan marketing materials can make it seem as though they are covering additional services, when these services are actually covered by Medicare.
  • If I am signing up for a Medicare Advantage Plan because it contains this benefit, did I also make sure that the plan’s coverage will work for me?
    • For example, are all of my providers in the plan’s network? Are all of my drugs on this plan’s formulary?
  • Is this benefit offered to all enrollees in this Medicare Advantage Plan?
    • Is it an optional benefit that I need to sign up for?
    • Is it a benefit that is only offered to plan members with chronic conditions? Do I meet the plan’s criteria for coverage?
    • Is the benefit only available if medically necessary? Does my situation meet that standard?
  • Is there a cost associated with this benefit?
    • Is there an additional premium that I must pay in order to access it?
    • Are there copays or coinsurances for these services?
    • Is this Medicare Advantage Plan’s premium higher than comparable plans that do not offer this benefit
  • Are there limits on how much I can use this service—for example, a set number for rides for a transportation benefit or a dollar limit on eyeglasses?
  • Are there restrictions on where and how I can access these services? For example, do I need to see in-network providers, receive a referral, or participate in a care management program?
  • Are there some excluded services within this category of benefits?
  • Is this the most cost-effective way for me to access these services?
  • Is separate insurance or private payment for that benefit available? Does that insurance offer more benefits or is it less expensive than the premium difference?