Medicare Advantage (Part C)

SHARE

Medicare Advantage (Part C)

Medicare Part C is available through Medicare Advantage plans, and is an alternative to Original Medicare (Part A and Part B). Medicare Advantage plans are health insurance plans offered by private health insurance companies approved by Medicare. Medicare Advantage health plans (such as HMOs and PPOs) are legally required to offer at least the same benefits as Original Medicare, but can include additional coverage as well, such as routine vision or dental benefits, health wellness programs, or prescription drugs.

Differences Between Original Medicare and a Medicare Advantage Plan

Original MedicareMedicare Advantage Plans
CostsYou pay Medicare premiums, deductibles, and coinsurances (usually 20 percent of the Medicare-approved cost for outpatient care).You pay Medicare premiums and your plan’s premium, if it charges one. Your plan sets its own deductibles and copays (usually a fixed cost for each office visit). You may pay the full cost if you don’t follow your plan’s rules.
Supplemental InsuranceYou can buy a Medigap policy. (But only at certain times, depending on where you live.)You can’t buy a Medigap policy to help pay your out-of-pocket costs in a Medicare Advantage plan.
Covers extra services like vision and dental?No. Covers medically-necessary inpatient and outpatient health care. Doesn’t cover certain services such as routine vision, hearing or dental care.Maybe. May cover some services Original Medicare doesn’t cover such as routine vision, hearing and dental care. All plans must cover the same inpatient and outpatient services Original Medicare covers.
Lets me see providers nationwide?Yes. You can go to any doctor or hospital in the U.S. that accepts Medicare.Usually not. Most people have HMOs, which typically have local networks of providers you must use for the plan to cover your care. PPOs and PFFS plans should cover care you get outside the network, but you will pay more.
Need referrals to see specialists?No. You don’t need a referralMaybe. You often need to get a referral from your Primary Care Physician if you want to see a specialist.
Covers drugs?No, but if you want Medicare prescription drug coverage, you can buy a separate Part D plan.Usually. Most plans include Part D drug coverage. You usually can’t get a separate Part D plan if you have a Medicare Advantage plan (some exceptions).
Out-of-pocket limit?No. There’s no cap on what you spend on health careYes. Plans must have an annual out-ofpocket limit, which can be high but protect you if you need expensive care. The plan pays the full cost of your care after you reach the limit.

What you pay in a Medicare Advantage Plan

The difference between Medicare Part C and Original Medicare is that all Medicare Advantage plans have a yearly out-of-pocket spending limit. Once you reach the plan limit (including the deductible), the Medicare Advantage plan covers 100% of covered medical services for the rest of the year. With Medicare Advantage plans, you have peace of mind knowing that there's a cap to your annual medical costs.

Medicare Part B generally includes monthly premiums unless you qualify for low-income assistance. In addition to paying your Part B premium, you may also be responsible for paying a Medicare Advantage premium. Premiums can range from $0 and up depending on your plan. You may want to compare all available plan options in your area to find a plan with costs and benefits that meet your needs. Remember, even if your service area offers a Medicare Advantage plan with a $0 premium, this doesn't mean that that plan won't have other costs. You'll still need to pay the Medicare Part B premium, along with any copayments, coinsurance, or deductibles required by the Medicare Advantage plan.

Your out-of-pocket costs in a Medicare Advantage Plan (Part C) depend on:

  • Whether the plan charges a monthly premium.
  • Whether the plan pays any of your monthly Medicare Part B (Medical Insurance) premium.
  • Whether the plan has a yearly deductible or any additional deductibles.
  • How much you pay for each visit or service (copayment orcoinsurance). For example, the plan may charge a copayment, like $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare.
  • The type of health care services you need and how often you get them.
  • Whether you go to a doctor or supplier who accepts assignment (if you're in a PPO, PFFS, or MSA plan and you go out-of-network).
  • Whether you follow the plan's rules, like using network providers.
  • Whether you need extra benefits and if the plan charges for it.
  • The plan's yearly limit on your out-of-pocket costs for all medical services.
  • Whether you have Medicaid or get help from your state.

Medicare Advantage plans determine cost-sharing requirements for covered services, and each plan sets its own coinsurance percentages and terms. So it's a good idea to shop around and compare plan options to find coverage that fits your budget and offers the best value.

Keep in mind that Medicare Advantage plan costs may change from year to year, so it's important to review your coverage annually to make sure it's still meeting your needs.

How do I know which plan is right for me? The following are types of Medicare Advantage plans that may be available in your location:

  • Health Maintenance Organization (HMO) plans: These plans offer a network of doctors and hospitals that members are generally required to use to be covered. Because of this, HMOs tend to have strict guidelines, meaning that any visits and prescriptions are subject to the plan approval. If you use providers outside of the plan network, you may need to pay the full cost out of pocket (with the exception of emergency or urgent care). You generally need to get a referral from your primary care doctor to see a specialist.
  • Preferred Provider Organization (PPO) plans: Medicare Advantage PPO plans offer a network of doctors and hospitals for beneficiaries to choose from. Unlike an HMO, you have the option to receive care from health-care providers outside of the plan's network, but you'll pay higher out-of-pocket costs. Medicare Advantage PPOs don't require you to have a primary care doctor, and you don't need referrals for specialist care.
  • Private Fee-for-Service (PFFS) plans: This type of plan allows visits to any Medicare-approved doctor or hospital, as long as the plan's terms and conditions of payment are accepted by the provider. Keep in mind that you'll need to find providers that contract with the plan each time you are receiving treatment.
  • Special Needs Plans (SNPs): These plans limit enrollment to beneficiaries who have certain chronic conditions, are institutionalized, or qualify for both Medicare and state Medicaid (also known as dual eligibles). Benefits, provider options, and prescription drugs are tailored to meet the needs of the plan's enrollees.
  • Medicare Medical Savings Account (MSA) plans: These plans combine a high-deductible Medicare Advantage plan with a medical savings account. Every year, your MSA plan deposits money into a savings account that you can use to pay for medical expenses before you've reach the deductible. After your reach the deductible, your plan will begin to pay for Medicare-covered services. These plans don't cover prescription drugs; if you want Medicare Part D coverage, you may enroll in a stand-alone Medicare Prescription Drug Plan.

Eligibility

In order to be eligible for Medicare Part C, you must be enrolled in both parts of Original Medicare (Part A and Part B). Once you have Medicare Part A and Part B, you are generally able to enroll in a Medicare Advantage plan, provided you live in the plan's service area and do not have end-stage renal disease (ESRD).

There are some exceptions where you may be able to enroll in a Medicare Advantage plan even if you have end-stage renal disease. For example, if you're enrolling in a Special Needs Plan that targets beneficiaries with end-stage renal disease, you may be eligible to enroll in this type of Medicare Advantage plan. To learn more about other situations where you may be eligible for Medicare Part C if you have end-stage renal disease, you can contact Medicare at 1-800-MEDICARE (1-800-633-4227); 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.

Those with other health insurance coverage (a union or employer-sponsored health plan, for example) should get more information about their existing coverage before enrolling in a Medicare Advantage plan. It is possible you could lose your existing coverage once you enroll in a Medicare Advantage plan. Furthermore, if you discontinue the other plan for Medicare Part C coverage, you may not be able to reinstate your original coverage if you change your mind It is generally a good idea to check with your current benefits administrator before you enroll in another health-care plan.

How do I join a Medicare Advantage Plan?

Not all Medicare Advantage Plans work the same way, so before you join, take the time to find and compare Medicare health plans in your area. Once you understand the plan's rules and costs, here's how to join:

  • Use Medicare's Plan Finder.
  • Visit the plan's website to see if you can join online.
  • Fill out a paper enrollment form. Contact the plan to get an enrollment form, fill it out, and return it to the plan. All plans must offer this option.
  • Call the plan you want to join. Get your plan's contact information from a Personalized Search (under General Search), or search by plan name.
  • Call 1-800-MEDICARE (1-800-633-4227).

When you join a Medicare Advantage Plan, you'll have to give your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card