Medicare Part C (Medicare Advantage)
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Medicare Advantage (Medicare Part C)
Medicare Advantage (Medicare Part C) policies are purchased from private insurers approved and contracted by Medicare.
Medicare Advantage plans are approved by Medicare but are run by private companies. These companies provide Medicare Part A and Part B covered services and may include Medicare drug coverage too. Medicare Advantage plans are sometimes called “Part C” or “MA” plans. MA plans are not supplemental insurance.
Medicare Advantage (Medicare Part C) is an alternative to Original Medicare.
You will still need to sign up for Medicare Parts A & B before signing up for Medicare Advantage (Part C).
You should research your Original Medicare options (e.g. Parts A, B, D, Medicare Supplement (Medigap) thoroughly before electing to take a Medicare Part C (Medicare Advantage) plan. Refer to some of the Limitations/Questions section listed later on the page.
Disclaimer: for specific details for signing up for Medicare and Medicare Advantage (Part C) plans, contact Medicare direct (Medicare.gov or 1-800-633-4227 (1-800-MEDICARE)) or contact the Social Security Administration (https://www.ssa.gov/benefits/medicare/ or 1-800-772-1213).
You’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) benefits/coverage from the Medicare Advantage Plan (private insurer) and not Original Medicare. Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.
Use this brief summary to compare Original Medicare and Medicare Advantage (Part C).
You can use the Medicare site to Find a Medicare Advantage Plan in your area. You do not have to have an account. You can select the option for “Continue without logging in”. You’ll first enter your zip code. You will be prompted to select what types of Medicare coverage you want to review or you can select the “What type of plan should I choose?” link to review a brief description of Medicare Advantage (Part C), Medicare Drug Plan (Part D), or Medigap Policy”. Select Medicare Advantage Plan (Part C) to review Medicare Advantage health plans (not Original Medicare) in your zip code. You’ll then answer a few more questions. You can answer the questions different ways and search multiple times. You’ll then see a list of available Medicare Advantage plans in your area. Each of the plan names will indicate if it is an HMO, PPO, or other. Select the Plan Details button for any individual plan to drill down to see more details about the plan, which will also include a link directly to the plan providers web site for even more information.
Medicare Advantage policy costs vary. Costs may include:
-
- Premiums
- Coinsurance or co-pays
- There will be the standard monthly premium for Medicare Part B (e.g. $185.00), but you can check with the Medicare Advantage plan to see if it covers some or all of the Medicare Part B premium.
As with most any of the Medicare options, coverage can vary and out-of-pocket limits and maximum payouts can vary.
You must first enroll in Medicare Part A and Part B to purchase Medicare Advantage (Medicare Part C).
Medicare Advantage (Part C) may be less expensive than separately obtaining benefits from Medicare Plan A, Plan B, Plan D, and Medigap. However, there may be limitations on coverage areas and provider (doctors, hospitals, etc.) selection.
Types of Medicare Advantage Plans include:
Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Private Fee-for-Service Plans (PFFS)
Special Needs Plans (SNP)
Medicare Medical Savings Account Plans (MSA)
Many (if not most) Medicare Advantage Plans include prescription coverage. Prescription Drug Coverage is optional. However, if you want/need prescription drug coverage you must sign up for it through your Medicare Advantage Plan. In most cases you will not be able to obtain a separate Medicare Part D Prescription Drug plan without changing back to Original Medicare. Refer to the How to get prescription drug coverage page. Refer to the 2nd way to get Medicare drug coverage topic, via a “Medicare Advantage Plan (Part C) or other Medicare health plan with drug coverage”. Also refer to the “Joining a Medicare drug plan may affect your Medicare Advantage Plan” topic. Basically, if you elect to use a Medicare Advantage plan (Part C) and want drug coverage, you need to pick a Medicare Advantage plan that offers drug coverage, except in a few instances.
It is possible if you decide not to get Medicare drug coverage when you’re first eligible, you’ll likely pay a late enrollment penalty unless one of these applies: You have other creditable prescription drug coverage or You get Extra Help. Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductible, and coinsurance.
Many Medicare Advantage Plans also offer extra coverage, like vision, hearing and dental coverage.
If you have a Medicare Advantage Plan, it’s illegal for anyone to sell you a Medigap policy unless you’re switching back to Original Medicare.
If you want to switch to Original Medicare and buy a Medigap policy, you should call Medicare at 1-800-MEDICARE. You want to be totally aware of any issues as to when you can switch, how much it will cost, will a Medigap insurance provider accept your application, will your pre-existing conditions covered, etc. You should also contact your Medicare Advantage Plan to see if you’re able to disenroll. Refer to the “Medigap & Medicare Advantage Plans” topic, first bullet.
If you join a Medicare Advantage Plan for the first time, and you aren’t happy with the plan, you’ll have special rights under federal law to buy a Medigap policy. Refer to the “Medigap & Medicare Advantage Plans” topic, second bullet. Also, you can use the Medicare website, “When can I buy a Medigap policy?” to help determine if you have a right to buy a Medigap policy if you return to Original Medicare. You usually have these rights if you return to Original Medicare within 12 months of joining a Medicare Advantage plan.
Guaranteed issue rights (also called “Medigap protections”) (scroll down to the link for What are guaranteed issue rights?) are rights you have in certain situations when insurance companies must offer you certain Medigap policies. Thus allowing you to return to Original Medicare and drop the Medicare Advantage Plan.
Limitations of Medicare Advantage (Medicare Part C)/Questions:
- You may need to use health care providers (doctors, hospitals, etc.) who participate in the plan’s network, i.e. you may not be able to use your current providers (doctors, hospitals, etc.).
- You may have a limited coverage area.
- You may have a limited coverage area and have to pay more out-of-pocket if you go to a provider out of the coverage area.
- There may be stricter rules for certain services, health products, or referrals.
- May not be a good fit if you have ongoing health issues.
- May not be as flexible for your treatment options as Original Medicare.
- Medicare Advantage plans have annual contracts with Medicare and can choose not to renew their contract for the following year.
- What if you move to a different location (e.g. State, city, county, part of a state, etc.)?
- Can you disenroll and return to Original Medicare? Yes, but.
- If you start out with Medicare Part C (Medicare Advantage) and you don’t like it, you can generally switch back to Original Medicare during certain enrollment periods. However, Medicare Part D (prescription drug coverage) may cost more. In addition, you may not even be able to get a Medicare Supplement (Medigap) policy, and if you do it may cost more and have limitations.
Check plans to review their coverage for out-of-network emergencies and “urgently needed services”.
These are usually treated differently.
If you have ESRD (End-stage renal disease), you’ll usually get your health care through Original Medicare but you can also get coverage with an Medicare Advantage (Part C) plan. There are some variables. Refer to the “How do I get Medicare?” and “What are my Coverage options?” topics.