What Is Medicare Advantage (Part C) — in Plain Words

What Medicare Advantage is

Medicare Advantage Plans are sometimes called “Part C” or “MA Plans.”

They are Medicare-approved plans.

They are offered by private companies that must follow rules set by Medicare.

Medicare calls them “bundled” plans.

They include Part A and Part B, and usually Part D.

Part A is Hospital Insurance.

Part B is Medical Insurance.

Part D is Medicare drug coverage.

You still have Medicare

If you join a Medicare Advantage Plan, you will still have Medicare.

But you will get most of your Part A and Part B coverage from your Medicare Advantage Plan, not from Original Medicare.

The booklet says you will have the same rights and protections you would have under Original Medicare.

You must use the card from your Medicare Advantage Plan to get your Medicare-covered services.

Keep your red, white, and blue Medicare card in a safe place.

You may need to show your Medicare card for some services.

You will also need it if you ever switch back to Original Medicare.

You still pay the Part B premium

You still have to pay the Part B premium.

You may also have to pay the plan’s premium.

Some plans may have no extra monthly premium.

Some plans may help pay all or part of your Part B premium.

Costs for monthly premiums and for services vary depending on which plan you join.

This page prints no premium amounts. Medicare’s pages and the plan are the source for amounts.

What the plans must cover

Plans must cover all medically necessary services that Original Medicare covers.

Plans must cover all emergency and urgent care.

Medicare’s “How does Medicare work?” page says plans must cover almost all medically necessary services Original Medicare covers.

The booklet says that if you are in a Medicare Advantage Plan, Original Medicare will still help cover your costs for hospice care.

Drug coverage, in most plans

Most Medicare Advantage Plans include Medicare drug coverage (Part D).

That is why, in most cases, you don’t need to join a separate Medicare drug plan.

The booklet gives this detail:

• In certain types of plans that don’t include drug coverage, like Medical Savings Account plans and some Private Fee-for-Service plans, you can join a separate Medicare drug plan.
• If you join a Health Maintenance Organization or Preferred Provider Organization plan without drug coverage, you can’t join a separate Medicare drug plan.

Extra benefits some plans may offer

Plans may offer some extra benefits that Original Medicare doesn’t cover.

The booklet lists examples like these:

• Fitness programs, like gym memberships or discounts.
• Some vision services, like routine checkups.
• Some hearing services.
• Some dental services, like routine checkups or cleanings.

Not every plan offers the same extra benefits.

Each plan can have different rules for how you get services.

How it is different from Original Medicare: doctors and hospitals

With Original Medicare, you can use any doctor or hospital that takes Medicare, anywhere in the U.S.

With a Medicare Advantage Plan, you may need to use doctors and other providers who are in the plan’s network and service area, for non-emergency care.

Some plans offer non-emergency coverage out of network, but typically at a higher cost.

You may need to get a referral to use a specialist.

With Original Medicare, in most cases, you don’t need a referral to use a specialist.

How it is different: approval before some care

You may need to get approval from your plan before it covers certain services or items.

Medicare calls this prior authorization.

With Original Medicare, in most cases, you don’t need approval for Original Medicare to cover your services or items.

How it is different: a yearly limit on what you pay

Medicare Advantage Plans have a yearly limit on what you pay for covered Part A and Part B services.

The limit may include different limits for in-network and out-of-network services.

Once you reach your plan’s limit, you will pay nothing for covered services for the rest of the year.

With Original Medicare, there is no yearly limit on what you pay out of pocket, unless you have supplemental coverage.

This page prints no limit amounts. Each plan sets its own limit, and the plan is the source for its amount.

Costs and rules can change each year

Each Medicare Advantage Plan can charge different out-of-pocket costs.

Each plan can have different rules for how you get services.

These costs and rules can change each year.

The plan must notify you about any changes before the start of Open Enrollment for the next year.

It does this through the Annual Notice of Change.

These notices are typically mailed before September 30.

Open Enrollment is October 15 to December 7 every year.

Medigap does not work with Medicare Advantage

Medigap is Medicare Supplement Insurance.

It helps pay a share of out-of-pocket costs in Original Medicare.

Medigap does not work with Medicare Advantage. It only works with Original Medicare.

The booklet says you can’t buy Medigap to cover your Medicare Advantage Plan out-of-pocket costs.

It also says you can’t use Medigap to pay your Medicare Advantage Plan copayments, coinsurance, deductibles, and premiums.

The booklet also says this:

If you are in a Medicare Advantage Plan, it is illegal for anyone to sell you a Medigap policy unless you are switching back to Original Medicare.

The types of Medicare Advantage Plans

The booklet lists several types of Medicare Advantage Plans.

The area where you live might have all, some, or none of these plan types.

There might also be more than one plan of the same type in your area.

• Health Maintenance Organization (HMO) Plan. You generally must get your care from doctors, other health care providers, or hospitals in the plan’s network. Emergency care, out-of-area urgent care, and temporary out-of-area dialysis are exceptions. Many HMOs also require a referral from your primary care doctor for specialist care. In most cases, you need to choose a primary care doctor.
• HMO Point-of-Service (HMOPOS) Plan. Some HMO plans, known as HMOPOS plans, offer an out-of-network benefit for some or all covered benefits. You will usually pay a higher copayment or coinsurance.
• Preferred Provider Organization (PPO) Plan. This plan has a network of doctors, specialists, hospitals, and other providers. You pay less if you go to providers in the plan’s network. You can generally go to out-of-network providers for covered services, but you will usually pay more.
• Private Fee-for-Service (PFFS) Plan. This plan is offered by a private health insurance company. The plan decides how much it will pay doctors, other providers, and hospitals, and how much you must pay when you get care. You can go to any Medicare-approved doctor, provider, or hospital that accepts the plan’s payment terms and agrees to treat you.
• Special Needs Plan (SNP). These plans give benefits and services to people with specific severe or chronic diseases, certain health care needs, or who have Medicaid coverage. All SNPs must include Medicare drug coverage (Part D).
• Medical Savings Account (MSA) Plan. These plans combine a high-deductible insurance plan with a medical savings account. The plan deposits money into your account that you can use to pay for health care costs. MSA Plans do not cover prescription drugs. If you want drug coverage, you have to join a separate Medicare drug plan.

Who can join, in Medicare’s words

The booklet says, to join a Medicare Advantage Plan, you must:

• Have Part A and Part B.
• Live in the plan’s service area.
• Be a U.S. citizen or lawfully present in the U.S.

The booklet also says you can join a Medicare Advantage Plan even if you have a pre-existing condition.

It also says you can join a Medicare Advantage Plan even if you have End-Stage Renal Disease (ESRD).

This page does not decide if any one person can join. That is a fact to check through the official routes below.

When you can join or switch

You can only join, switch, or drop a Medicare Advantage Plan at certain times, called enrollment periods.

The booklet lists these times, among others:

• Open Enrollment Period: Between October 15 and December 7 each year, anyone with Medicare can join, switch, or drop a Medicare Advantage Plan. Coverage will begin on January 1 of the following year, as long as the plan gets your request by December 7.
• Medicare Advantage Open Enrollment Period: Between January 1 and March 31 each year, if you already have a Medicare Advantage Plan, you can switch to another Medicare Advantage Plan, or drop your plan and return to Original Medicare. You can also join a separate Medicare drug plan then.
• Initial Enrollment Period: When you first become eligible for Medicare, you can join a Medicare Advantage Plan if you have both Part A and Part B, during your Initial Enrollment Period.

Where to check plans and facts for one person

This page gives general information only.

It does not give any one person’s plan, coverage, or costs.

The booklet prints these official routes:

• Medicare.gov/plan-compare. Visit Medicare.gov/plan-compare to find and compare Medicare Advantage Plans in your area. You can also search by ZIP code to find a plan and join.
• Medicare. Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
• The plan. Call the plan you want to join, or visit the plan’s website, to find out if you can join online. You can also ask the plan for a paper enrollment form.