Medicare Advantage Plans

Part C

Medicare Advantage plan or Part C is a private Medicare plan that covers Medicare Part A and B. All the same benefits as Original Medicare, and may include benefits Original Medicare doesn't cover, like hearing, dental, vision care and wellness services.

Part C also has a yearly limit on out-of-pocket costs for covered medical services, unlike Original Medicare.

How do Medicare Advantage plans work?

Medicare pays a fixed amount for your coverage each month to the company offering your Medicare Advantage Plan. Each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to doctors, facilities, or suppliers that belong to the plan’s network for non-emergency or non-urgent care). These rules can change each year. The plan must notify you about any changes before the start of the next enrollment year. If you join a Medicare Advantage Plan, you’ll have all of the same rights and protections that you would have under Original Medicare.

Who can enroll?

You can join a Medicare Advatage Plan if:

You are a US citizen or lawfully present in the US.
You have a Medicare Part A and B.
You live in the service area of the plan you want to join.

When can I enroll?

The same enrollment period for Parts A and B (3 months before the month you turn 65 to 3 months after the month you turn 65).
During the Annual Enrollment Period (October 15 - December 7). Your coverage will begin on January 1.
During a Special Enrollment Period for special circumstances such as: losing your employee coverage, moving to a new service area or qualifying for extra help.

What do I need to enroll?

When you join a Medicare Advantage Plan, you will have to give these:

Your Medicare number
The date your Part A and/or Part B coverage started (can be found in your Medicare card)

How much does Part C cost?

Each plan has different out-of-pocket maximums, different access to doctors, and other varying features which may change annually. Many Part C plans have a $0 premium. Others can go as high as $200 a month, or more, which is in addition to your monthly Part B premium. In 2023, the standard Part B premium amount is $164.90 (or higher depending on your income). Some people with Social Security benefits pay less.

Do I still have to pay for Medicare Part B if I join the Medicare Advantage Plan?

Yes, participation in Medicare Part B is required to participate in a Medicare Advantage Plan.

Which plan is right for me?

There are few questions to consider when choosing the right plan for you. When you are choosing a Medicare Advantage plan, ask yourself:

What monthly plan premium can I afford?
Does the plan cover the services I need?
Can I see the doctors I want?
What prescription drugs do I take or will I need?
What medical conditions do I have, and what are my long-term healthcare needs?
Are there extra benefits I would use?
What is the plan’s quality rating?

Most common types of Medicare Advantage Plans

Health Maintenance Organization (HMO) Plans
The plan may require members to get referrals from a primary care physician in order to see specialists in their network. They may also change coverage and/or premiums annually. There may be additional costs such as hospital and skilled nursing facility co-payments.

There may be prior authorization (approval) requirements for certain services. Also, providers can choose to no longer participate with an HMO plan during the year. Even participating providers may decide at any point that they are not accepting new patients under the Medicare HMO plan. Generally, members are required to use only health care providers in the HMO plan’s network.

Preferred Provider Organization (PPO)
PPOs provide some coverage for services provided outside of their network. Cost-sharing amounts will usually be lower when beneficiaries use network providers than when they use out-of-network providers. A PPO must have a sufficient network of providers so that enrollees can get all services within the plan. Also, with a PPO, a member does not have to get a referral to see a specialist. Premiums are usually more than HMO premiums, but less than premiums for Medicare Supplement insurance.

Private Fee-for-Service (PFFS) Plans
This type of plan sets its own payment structure. The plan decides how much it will pay its Medicare providers, and how much you will pay as a patient. Under this plan, a person with Medicare may go to any Medicare-participating medical provider or any hospital, as long as the provider or hospital accepts the plan’s payment terms. PFFS plans also have networks of providers and are very similar to PPO plans. No referrals are necessary. Costs may include a monthly premium and an amount per visit or service.

Special Needs Plans (SNP)
This plan is designed to serve people with specific health conditions, or meet certain other qualifications. It is only available for those with both Medicare and Medicaid (which may include those with QMB only without Medicaid), institutionalized beneficiaries or those with certain chronic conditions. SNPs may offer more focused and specialized health care as well as better coordination of care for these beneficiaries than other types of Medicare Advantage plans. All SNPs include Part D drug coverage.