What You Should
Know About
Medicare Advantage

What You Need to Know about Medicare Advantage

What is Medicare Part C?

Medicare Part C Plans (also known as Medicare Advantage Plans or Part C) are offered by Medicare-approved private health insurance companies rather than the government. Part C plans combine the coverage you would get in Part A and Part B and usually include additional benefits like prescription coverage, dental, vision, and hearing. They also set limits on your out-of-pocket costs for the year for covered services to protect you from unexpected costs. Generally, you will need to use healthcare providers within your plan’s network to get the lowest costs; however, some plans may offer out-of-network coverage, possibly at a higher cost.

 

Common types of Medicare Advantage Plans:
  • Private Fee-for-service (PFFS) Plans
  • Health Maintenance Organization (HMO) Plans
  • Special Needs Plans (SNPs)
  • Preferred Provider Organization (PPO) Plans
Less common Medicare Advantage Plans:
  • Hmo Point of service (Hmopos) Plans
  • Medicare Medical Saving Account (Msa) Plan

What does Medicare Advantage cover?

Medicare Advantage Plans cover all of the services Original Medicare covers, as well as emergency and urgently needed care. But, even if you have a Medicare Advantage Plan, Original Medicare still covers the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.

In addition to what is covered in Part A & Part B, Medicare Advantage plans can offer additional coverage and benefits. Some plans will cover dental, vision, hearing, and some fitness programs. Plans could also provide coverage and services like transportation to doctors visits, over-the-counter drugs, and other services promoting health and wellness. Plans can offer tailored benefit packages to certain chronically-ill enrollees designed to treat specific conditions.

Always check with the plan before you enroll to see the offered benefits, if you qualify, and if there are limitations.

If a service isn’t considered medically necessary, your plan may choose not to cover costs. Check with your provider if you are unsure if a service is covered.

You may have to pay the full cost of a service you need that isn’t considered medically necessary, but you have the right to appeal the decision.

You can request an organization determination if you have a Medicare Advantage Plan to check if a service, drug, or supply is covered. To get an organization determination, contact your plan and follow the instructions to file a timely appeal.

You may also get plan directed care (when your plan provider refers you for a service or to a provider outside your network without getting an organization determination beforehand)

How do I compare Medicare Advantage plans?

Medicare Advantage Plans vary in what they cost and cover, so it’s important to compare plans in your area. Medicare’s Plan finder on Medicare.gov can be used as a resource to find and compare plans.

When can I buy Medicare Advantage plans?

You can join a Medicare Advantage Plan during specific times of the year.

In addition to Special Enrollment periods, there are two different enrollment periods each year during which you can make changes to your Medicare Advantage or Medicare drug plan for the following year.

The Open Enrollment Period for Medicare Advantage and Medicare drug coverage (October 15th – December 7th)
Changes you can make:
  • Change from Original Medicare to a Medicare Advantage Plan.
  • Change from a Medicare Advantage plan back to Original Medicare.
  • Switch from one Medicare Advantage plan to another.
  • Switch from a Medicare Advantage plan without drug coverage to a Medicare Advantage plan without drug coverage.
  • Switch from a Medicare Advantage plan with drug coverage to a Medicare Advantage plan without drug coverage.
  • Enroll in a Medicare drug plan.
  • Switch from one Medicare drug plan to another.
  • Drop your Medicare coverage altogether.
The Medicare Advantage Open Enrollment Period (January 1st – March 31st)
Changes you can make:
  • Switch from a Medicare Advantage plan without drug coverage to a Medicare Advantage plan with drug coverage.
  • Switch from a Medicare Advantage plan with drug coverage to a Medicare Advantage plan without drug coverage.
  • Change from a Medicare Advantage plan back to Original Medicare.
  • Enroll in a Medicare drug plan.

You can change to another Medicare Advantage plan or go back to Original Medicare within the first 3 months of having Medicare if you enrolled in a Medicare Advantage Plan during your initial enrollment period.

How do I switch Medicare Advantage plans?

Switching Medicare Advantage plans is simple. Join the new plan you want during one of the enrollment periods. When your new plan’s coverage begins, you will be automatically disenrolled from your old plan.

When you switch, you should look at Medicare prescription drug coverage (Part D) if you don’t already have other drug coverage. You may also want a Medicare Supplement Insurance (Medigap) policy. You may only be able to switch during certain times of the year.

What are the costs of Medicare Advantage?

What you pay for a Medicare Advantage plan varies depending on several factors. Your out-of-pocket costs will depend on:
  • If the plan changes a monthly premium (several Medicare Advantage Plans have a $0 premium. If you join a plan that does charge a monthly premium, you will pay it along with the Part B premium (and the Part A premium if you don’t have a premium-free Part A)).
  • If your plan pays any of your monthly Medicare Part B premium (Some plans may pay part of or all of your Part B premium).
  • If your plan has a yearly deductible or any additional deductibles.
  • How much you pay for a visit or service (copayment or coinsurance). For example, some plans may change a copayment of $10 or $20 per doctor visit (These amounts can be different than those under Original Medicare).
  • If you go to a doctor or supplier who accepts assignment if you are in a PPO, PFFS, or MSA plan, or you go out-of-network.
  • Which healthcare services you need, and how often you need them.
  • If you follow the plan’s rules, such as using network providers.
  • If you need extra benefits and if the plan charges for them.
  • What the plan’s yearly limit on your out-of-pocket costs for medical services is.
  • If you have Medicaid or receive help from your state.
If you have a Medicare Plan, each fall you will be sent these notices concerning your plan:
  • “Evidence of Coverage” (EOC) – This notice provides details about what the plan covers, how much you pay, and more.
  • “Annual Notice of Change” (ANOC) – This notice provides details about any changes in coverage, cost, and more coming into effect in January.

If you do not receive these important documents, contact your plan.

Original Medicare Part A & B vs. Medicare Part C

While individual plans will vary, there are overarching differences to consider when deciding between Original Medicare and a Medicare Advantage Plan.

 

Doctor and hospital choice
Original Medicare
  • You can be seen by any doctor and go to any hospital in the US that takes Medicare. (In most cases, you will not need a referral to see a specialist.)
Medicare Advantage
  • In most cases, you will only see doctors and other providers in your plan’s network (for non-emergency care). Some plans may offer non-emergency coverage out of network; however, it may be at a higher cost. You may need a referral to see a specialist with a Medicare Advantage Plan.
Cost
Original Medicare
  • For Part B covered services, you will generally pay 20% of the Medicare-approved amount after meeting your deductible (also known as coinsurance).
  • You will pay a monthly premium for Part B. If you join a Medicare drug plan, you will pay a separate premium for Medicare drug coverage (Part D)
  • What you pay out-of-pocket will not have a yearly limit unless you have supplemental coverage (like Medicare Supplement Insurance (Medigap))
  • You may be able to get Medigap to help pay your remaining out-of-pocket costs. Or, you can use coverage from a former employer or union or Medicaid.
Medicare Advantage
  • Your out-of-pocket costs may vary depending on the plan.
  • You will pay a monthly Part B premium, and you may have to pay the plan’s premium in addition. Your plan may have a $0 premium and may help pay all or part of your Part B premium (most Medicare Advantage plans include Medicare drug coverage (Part D)).
  • Your out-of-pocket cost for services Medicare Part A and Part B cover will have a yearly limit. After reaching your plan’s limit, you will pay nothing for services Part A and Part B cover for the rest of the year.
  • You cannot buy and do not need a Medigap policy.
Coverage
Original Medicare
  • Original Medicare will cover most medically necessary services and supplies in hospitals, doctor’s offices, and other healthcare facilities (some benefits, like eye exams, most dental exams, and routine exams, are not covered under Original Medicare).
  • You can get Medicare drug coverage by joining a separate Medicare drug plan.
  • For most cases, you will not have to get a service or supply approved ahead of time for Original Medicare to cover it.
Medicare Advantage
  • Medicare Advantage plans must cover all medically necessary services that Original Medicare covers. Many plans offer additional benefits that Original Medicare does not cover (like some routine exams and vision, hearing, and dental services).
  • Most plans include Medicare drug coverage (Part D). With most Medicare Advantage plans, you cannot join a separate Medicare drug plan.
  • In some cases, you may need to get a service or supply approved ahead of time for the Medicare Advantage plan to cover it.
Foreign Travel
Original Medicare
  • Generally, Original Medicare will not cover care outside of the US. You might be able to buy a Medigap policy that covers emergency care outside the US.
Medicare Advantage
  • Medicare Advantage plans will not generally cover care outside the US; however, some plans may offer coverage of emergency and urgently needed services when traveling outside of the US through a supplemental benefit.