While most people are familiar with Parts A, B and D of the Medicare alphabet, Medicare Part C, or a Medicare Advantage Plan, is less well known. Offered by many of the same insurance companies you might have had before you were covered under Medicare, these plans, including arrangements similar to an HMO or PPO, are another health coverage choice you may have as part of your Medicare options. Here are some of the details you’ll find in the Medicare & You booklet that can now be accessed online at http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf.
Medicare Advantage Plan Facts
- Medicare Advantage Plans, sometimes called “MA Plans,” are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, the plan will provide all of your Part A (hospital insurance) and Part B (medical insurance) coverage. Most include Medicare prescription drug coverage (Part D). Note that you must not join both a Medicare Advantage Plan that includes prescription drug coverage and a Medicare Prescription Drug Plan, or else you will be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.
- In all plan types, you are always covered for emergency and urgent care.
- Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Medicare covers hospice care even if you are in a Medicare Advantage Plan.
- Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs.
- In addition to your Part B premium, you usually pay one monthly premium for the services provided. Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of‑pocket costs and have different rules for how you get services. For instance, you may be required to get a referral to see a specialist or you may have to go to only doctors, facilities or suppliers that belong to the plan for these to be covered.
- You can generally join a Medicare Advantage Plan if you have Part A and Part B and live in the service area of the plan.
- As with Original Medicare, you still have Medicare rights and protections, including the right to appeal.
- Medicare Advantage Plans aren’t considered supplemental coverage. You don’t need to buy (and can’t be sold) a Medigap (Medicare Supplement Insurance) policy while you are in a Medicare Advantage Plan. It won’t cover your Medicare Advantage Plan deductibles, copayment, or coinsurance. If you already have a Medigap policy, you can’t use it to pay for any expenses you have under a Medicare Advantage Plan. If you drop your Medigap policy to join a Medicare Advantage Plan, in most cases, you won’t be able to get it back.
- If you have other coverage, talk to your employer or organization’s benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose employer or union coverage. In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the plan you join. Remember, if you drop your employer or union coverage, you may not be able to get it back.
- You can join a Medicare Advantage Plan even if you have a pre‑existing condition, except for some cases of End‑Stage Renal Disease.
- You can only join a plan at certain times during the year. In most cases, you are enrolled in a plan for a year.
- If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan.
- If the plan decides to stop participating in Medicare, you will have to join another Medicare health plan or return to Original Medicare.
Medicare Advantage Plan Types
Medicare Advantage Plans include the following:
- Health Maintenance Organizations or HMOs
- Preferred Provider Organizations or PPOs
- Private Fee‑for‑Service (PFFS) Plans
- Medical Savings Account (MSA) Plans
- Special Needs Plans (SNP)
Other less common types of Medicare Advantage Plans include:
- Point of Service (POS) plans are similar to HMOs, but may enable you to get some services out‑of‑network for a higher cost.
- Provider Sponsored Organizations or PSOs are plans run by a provider or group of providers; in a PSO, you usually get your health care from the providers who are part of the plan.
Not all Medicare Advantage Plans work the same way or offer the same benefits. Before you join, it’s vital to find out the plan’s rules, what your costs will be and whether the plan will meet your needs. You can find out what types of plans are available in your area by visiting www.medicare.gov and selecting “Compare Health Plans and Medigap Policies in Your
Area.” You can also call 1‑800‑MEDICARE (1‑800‑633‑4227).
TTY users should call 1‑877‑486‑2048. Then contact the plans you are
interested in to get more information.
Medicare Advantage Plan Costs
Your out‑of‑pocket costs in a Medicare Advantage Plan depend on the
- Whether the plan charges a monthly premium in addition to your Part B premium.
- Whether the plan pays any of the monthly Part B premium. Some plans offer this option, usually for an extra cost.
- Whether the plan has a yearly deductible or any additional deductibles.
- How much you pay for each visit or service—the copayments or co-pays.
- The type of health care services you need and how often you get them.
- Whether you follow the plan’s rules, like using network providers.
- Whether you need extra coverage and what the plan charges for it.
- Whether the plan has a yearly limit on your out‑of‑pocket costs for all medical services.
To learn more about your costs in specific Medicare Advantage Plans,
contact the plans you are interested in to get more details. Keep in mind that when you compare all these factors to what you are paying with Original Medicare, a Medicare Advantage Plan might not be the best option for you.