Medicare Advantage Plans: Medicare Part C
Medicare Advantage Plans are offered by private insurance companies and provide all of your Part A and Part B benefits (many also include prescription coverage)
This guide contains useful information about Medicare Advantage (Medicare Part C) and offers an easy to understand overview of the benefits and conveniences of these plans. Medicare Advantage plans can be a cost-effective health insurance option as Medicare Advantage plans can have lower out of pocket costs, reduced deductibles and maximum out of pocket limits (MOOPs) providing predictability and potential savings.
What is Medicare Advantage? Overview and Basics for Medicare Part C
Medicare Advantage, also known as Medicare Part C, are Medicare plans offered by private insurance companies approved by the Centers for Medicare & Medicaid Services (CMS). Medicare Advantage is required by law to give you benefits as good or better than Original Medicare (Medicare Part A and Part B). Some Medicare Advantage plans also provide prescription drug coverage (Medicare Part D). Many enrollees enjoy the ease of convenience of having all of these services in one convenient plan.
In addition to prescription coverage, some Medicare Advantage plans may offer additional benefits* depending on your service area such as:
- Vision care
- Routine dental coverage
And some may include allowances for certain qualifying members that may help pay for groceries and other special supplemental benefits, including:
- Gym memberships (in some cases)
- Transportation to and from your doctor’s office (in some cases)
- Some even offer help paying utility bills for chronically ill members who meet qualifying criteria
Medicare Advantage plans can also offer low monthly premiums, and also help enrollees save money on:
- Copays
- Coinsurance
- Deductibles
*There may not be a plan in your area that has these benefits in one plan
Medicare Advantage offers an all-in-one health-care solution with coverage for doctor visits, outpatient services, hospital care and some plans have additional benefits like routine dental care. Plans can choose to not cover the cost of services if they are deemed medically unnecessary, so if you aren’t sure whether a service is covered, check with your provider first.
Medicare Advantage Networks
Medicare Advantage Plans typically use HMO, PPO or PFFS networks. Below is the list of the Medicare Advantage Networks, and how they work.
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Health Maintenance Organizations (HMO)
These networks have a specific network of select physicians and may require referral from a primary care physician before a patient can see a specialist. HMOs also provide additional benefits, like coverage for deductibles and more.
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Preferred Provider Organization (PPO)
A preferred provider organization allows customers to save money when they use a physician inside the plan's network. Customers are still able to see doctors outside the network, but might have to pay a higher cost.
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Private Fee-For-Service (PFFS)
Private Fee-For-Service plans work similarly to that of Original Medicare, but the plan determines how much it will pay the physician or facility and how much the patient will pay out-of-pocket.
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HMO “Point of Service” (HMOPOS)
A HMO “Point-of-Service" plan operates like a HMO but allows for some services to be covered by an out-of-network physician often for a higher copayment or coinsurance.
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Medical Savings Account (MSA)
A Medical Savings Account plan combines a high-deductible plan with a bank account where money is deposited by the plan to be used for health care services.
Bear in mind that some plans may change networks, so it’s important to review your plan annually to ensure it still meets your health-care needs and fits within your financial circumstances.
Why Should I Have a Medicare Advantage Plan?
Consider your health needs and financial position when deciding on coverage. Typically, Medicare Advantage plans are good for individuals seeking a comprehensive, convenient health care experience because they cover Medicare Parts A & B benefits and, potentially, offer other benefits and access to health and wellness programs.
You should also carefully consider the accessibility of health care provider networks since Medicare Advantage has network restrictions. People living in areas with more provider networks will have more choices, and greater accessibility to plan services, when it comes to Medicare Advantage.
Key Advantages of Medicare Advantage
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Includes coverage for Medicare Parts A & B
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Access to additional benefits such as vision, dental, and hearing coverage*
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May have lower out-of-pocket costs than original Medicare
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Prescription drug coverage
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Access to Health & Wellness programs
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All in one convenient plan
*There may not be a plan in your area that has these benefits in one plan
What do Medicare Advantage Plans Cover?
Medicare Advantage plans cover a wide range of services for new and existing enrollees seeking convenient, well-rounded coverage. These include benefits not offered by Original Medicare, such as vision, hearing, and dental services as well as non-emergency care.
| Typically Cover | Most Include | Some Offer |
|---|---|---|
| Hospital Stays | Prescription Drug Coverage | Vision coverage |
| Doctor visits | Dental coverage | |
| Preventative care | Hearing aids and exams | |
| Durable medical equipment | Health and wellness programs | |
| Outpatient procedures | Transportation service to medical appointments | |
| Home health services | ||
| Mental health services |
What isn't covered by Medicare Advantage plans?
Covered services depend upon plan and provider. This means that not all plans will, for example, offer coverage for prescription drugs or health and wellness services.
In addition, Medicare Advantage typically does not offer:
- Long-term care
- Clinical trials/certain experimental treatments
- Care received outside the U.S.
- Coverage while traveling beyond your plan’s service area
Medicare Advantage vs. Medicare Supplement: Comparison and What to Know
If you have enrolled in Original Medicare, you’re probably aware that there are coverage gaps (often referred to as “holes”) that can be filled by opting for a Medicare Advantage or Medicare Supplement plan. Medicare Advantage Insurance plans, which are offered by Medicare-approved private insurance companies, offer the same benefits as Medicare Parts A and B and may cover services not offered under Original Medicare, like fitness programs.
Medicare Supplement Insurance, also known as Medigap, offers coverage designed to fill the gaps in Original Medicare. Medigap policies help pay some of the costs not covered by Original Medicare. If you have an Original Medicare plan and a Medigap policy, Medicare and your Medicare Supplement plan will each pay its share of covered health care costs.
| Area of Comparison | Medicare Advantage | Medicare Supplement |
|---|---|---|
Coverage | Covers all services under Medicare Parts A & B, and may offer additional benefits. | Covers specific out-of-pocket costs not covered by Medicare, such as deductibles, coinsurance and copays. |
Cost | Offers lower, or sometimes no monthly premiums. | Features consistent monthly premiums although these are often more expensive. |
Provider Network | Enrollees are limited to a provider network for coverage, with no coverage outside the U.S. | Enrollees may see any provider who accepts Medicare. |
Prescription Drug Coverage | Most Medicare Advantage plans include prescription drug coverage. | Does not cover Prescription Drug Plans; must enroll in Medicare Part D. |
Is Medicare Advantage right for me?
Determining whether Medicare Advantage is right for you will depend on what services you need based on your health and health-care needs, as well as your budget. It’s always important to evaluate the specifics of all your needs. If you’re not sure which coverage option is right for your needs, a licensed SmartMatch insurance agent can help you confidently make the right decision.
Medicare Advantage Enrollment periods
Initial Coverage Election Period (ICEP)
The Initial Coverage Election Period (ICEP) is the seven-month window starting three months before you're first eligible for Medicare Part A and B. For most adults, the ICEP starts three months before the month they turn 65. During this time you can sign up for any Medicare Advantage plan that suits your needs.
Medicare Fall Open Enrollment Period (AEP)
Medicare's Fall Open Enrollment — also known as the Annual Enrollment or Annual Election Period — is when Medicare beneficiaries can add, change or drop their Medicare Part D or Medicare Advantage Part C plan coverage for the next year. This period starts on October 15th and continues through December 7th of each year with coverage or plan changes taking effect on January 1st of the new year. Outside of this time, most people will only have a limited opportunity to change their Medicare Advantage plan coverage throughout the year.
The Medicare Advantage Open Enrollment Period
The Medicare Advantage Open Enrollment Period runs from January 1 through March 31 annually and allows those who are enrolled in a Medicare Advantage Plan to make a one-time change. You can either move to another Medicare Advantage Plan or disenroll from your Medicare Advantage plan and return to Original Medicare and purchase a Medicare Supplement Plan. Note, if you leave a Medicare Advantage Plan and return to Original Medicare, you may be required to answer health questions in order to qualify and obtain a Medicare Supplement Insurance Plan.
Special Enrollment Periods
When certain events occur in your life, you may be eligible for Special Enrollment Periods (SEP). Examples of when SEPs occur include when you move outside your current coverage network, you lose you current coverage, or your current plan's contract with Medicare changes. For more information on Special Enrollment Periods, visit Medicare.gov's page dedicated to SEPs.
Frequently Asked Questions About Medicare Advantage Plans
You are likely eligible for a Medicare Advantage Plan if you meet the following qualifications:
- Are enrolled in Parts A and B at time of application
- If you are age 65 or older
- You’re a U.S. citizen or lawfully reside in the service area of the plan you wish to join
- If you undergo medical underwriting through a written questionnaire
If you have employer coverage, you may still be eligible to enroll in Medicare Advantage if you meet the qualifications for Medicare coverage. It’s important to review your employer coverage to ensure you’re making the right decision for your budget and coverage needs
Medicare Advantage plans are offered by private insurance companies under contract with the Federal government, therefore, they vary in cost, coverage, copays, and deductibles. Some Medicare Advantage plans provide affordable or $0 premiums, with a variety of coverages and benefits not included in Original Medicare.
Note that even with a $0 premium Medicare Advantage plan, you’ll still pay a monthly premium for Part B, and a Part D premium if your Medicare Advantage plan does not include prescription drug coverage (MA-PD).
If you’re eligible for both Medicare and Medicaid, you’ll receive “dual eligibility” status, which allows you to take advantage of the benefits offered by each program. These are called Dual-Special Needs Plans.
If this applies to you, Medicare will typically be your primary insurance and Medicaid will be your secondary insurance. Medicare covers most of your health care costs and Medicaid will cover the remaining costs that Medicare does not cover.
Yes, during enrollment periods. You can switch to traditional Medicare from your Medicare Advantage plan during the Fall Open Enrollment Period, from Oct. 15 to Dec. 7 annually (your Medicare coverage will start Jan. 1 of the following year). In addition, there is the Medicare Advantage Open Enrollment Period (Jan. 1-March 31) as well as Special Enrollment Periods you may be eligible for based on life events.
If you make this switch and want drug coverage, sign up for a Medicare stand-alone prescription drug plan (unless you have coverage from a different source). If you elect to sign up for Part D coverage later, you may be penalized for late enrollment. It may also be worthwhile to buy a Medicare supplemental insurance policy or Medigap, which helps cover the cost-sharing requirements of traditional Medicare.
Yes, during enrollment periods. Switching from Medicare Advantage to Medicare Supplement (Medigap) coverage is possible if you meet the requirements. You’ll probably be required to answer certain underwriting questions. If you pass medical underwriting, you can enroll during enrollment periods during the year, including Fall Open Enrollment (Oct. 15 to Dec. 7) or Medicare Advantage Open Enrollment (Jan. 1 to March 31).
No, you must choose between the two. Medicare Advantage plans pay for features and benefits, such as vision and dental and fitness programs, beyond those available through Medicare Parts A and B. Medicare Supplement plans help cover out-of-pocket expenses, like coinsurance, copayments, and deductibles.
*There may not be a plan in your area that has these benefits in one plan
Yes, you will pay a monthly Part B premium as well as your Medicare Advantage Plan premium. Your Part B premium is set based on income levels that Medicare establishes in the fall of each year, for the ensuing year.
Understanding Medicare Advantage coverage can be an overwhelming process, with a variety of carriers, networks, industry terms, and definitions to understand. Working with a licensed SmartMatch agent can streamline this process. Your SmartMatch agent helps you understand and prioritize your needs, then delivers a variety of options for you to compare and make the right coverage plan decisions.
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