Understanding Medicare Advantage (Medicare Part C)

Medicare Advantage (MA), also known as Medicare Part C, is an alternative to Original Medicare. Offered by private insurance companies, MA plans are required to include the same Part A and Part B benefits of Original Medicare, but many recipients choose a Medicare Advantage plan because of the additional benefits offered. MA plans often include benefits that Original Medicare does not. 

While plans vary in costs and coverage, some additional benefits of a Medicare Advantage plan may include dental, vision, gym memberships or wellness services, and even hearing-related services, like hearing exams, hearing aids, and hearing aid fittings. Some MA plans may include prescription drug coverage or an allowance for OTC drugs. Some include transportation services or expanded coverage for emergency care while traveling.

Medicare Advantage plans allow you to bundle your benefits within one package, and unlike Original Medicare, MA plans have an annual maximum out-of-pocket limit. When this limit is reached, you will not be responsible for paying additional medical expenses for the remainder of the year. 

The additional services covered by plans are up to the discretion of your insurance provider. While each plan may vary, all Medicare Advantage plans provide coverage for services covered under Medicare Parts A and B. Costs can vary by plan, and comparing the plans available in your area is an important step in determining which plan is right for you.

Enrollment

Enrolling in Medicare means choosing which type of coverage you want. You can choose one of two ways to get your benefits: enroll in Original Medicare Part A (hospital insurance) and Part B (medical insurance) or enroll in a Medicare Advantage plan. You’ve probably heard about Medicare Part C but here are some basics about enrollment. You can enroll in a Medicare Advantage plan during you Initial Enrollment Period when you first qualify for Medicare. 

When you turn 65 years of age or if you qualify under the age of 65 due to disability, you may be eligible for Medicare. If you’re turning 65, you’ll have a 7 month Initial Enrollment Period that begins 3 months before your 65^th birthday, continues through your birthday month, and ends three months later. 

If you are under the age of 65 and have been receiving disability benefits from the Social Security Administration or Railroad Retirement Board for 24 months, you may be eligible for Medicare. If you’re diagnosed with ALS or ESRD you may qualify when you are diagnosed and may be eligible to join a Medicare Advantage Special Needs Plan that is designed for individuals with specific chronic illnesses.

How does Medicare Advantage differ from Original Medicare?

1. Medicare Advantage plans are required by law to cover the same benefits that are included in Original Medicare Parts A and B, but many plans provide additional benefits that can vary.

Medicare Advantage plan providers have the option to include benefits that Original Medicare doesn’t cover. Some commonly covered benefits include:

• Prescription drug coverage
• Routine dental care
• Routine hearing care and hearing aids
• Routine vision care plus eyeglasses and contacts
• Fitness club memberships
• Transportation to and from medical appointments
• Meal delivery services

2. Original Medicare allows beneficiaries to use any health care provider as long as they accept Medicare assignment. On the other hand, some Medicare Advantage plans require that you use health care providers, medical facilities, and medical suppliers that are included in the plan’s network. Depending on the type of plan you enroll in, you may also need a referral from your primary care physician to see a specialist. 3. Prescription drug coverage is generally included in most Medicare Advantage plans. If it isn’t, you can enroll in a stand-alone Medicare Part D plan as you would with Original Medicare. 

4. Medigap, or Medicare Supplement, plans only work with Original Medicare. You cannot purchase a Medigap plan if you have Medicare Advantage. 

Cost differences between Original Medicare and Medicare Advantage

• With Original Medicare you pay a monthly premium for Part B. If you have a Part D plan, you also pay a monthly premium for that coverage. 
• With Medicare Advantage you pay a monthly premium for the Part C plan (some plans have zero monthly premiums). You also pay your Medicare Part B premium to stay eligible for coverage. If your Part C plan doesn’t include prescription drug coverage, you may have a separate Part D premium also. 
• Medicare Part B has 20 percent coinsurance costs for most services. You must also meet your Part B deductible before Medicare begins paying. Your out-of-pocket costs vary depending on your Medicare Advantage plan, but they are generally lower for certain services. 
• Medicare Advantage plans have an annual out-of-pocket limit for covered services but Original Medicare doesn’t. If you have Part C coverage, you pay nothing for covered services after you reach your plan’s limit for the calendar year. With Original Medicare, there’s no annual limit unless you purchase a Medicare Supplement plan that includes a cap in its benefits.

Are there different types of MA plans?

Here’s a look at the four most common types of MA plans:

1. Health Maintenance Organization or HMO plans require enrollees to get care within the plan’s network except for emergency care, out-of-area urgent care, or out-of-area dialysis. HMOs tend to have lower out-of-pocket costs because of network restrictions. Many HMOs also include prescription drug coverage, but you should ask the insurance carrier for the details. Many HMOs will have you choose a primary care physician who will coordinate your care and give you referrals if you need to see a specialist.

2. Preferred Provider Organization or PPO plans offer enrollees the option to use in-network health care providers, facilities, and suppliers, but they can also use providers that are outside the network. You may have lower out-of-pocket costs if you use providers within the plan’s network, and you may pay more if you go outside the plan’s network. You may not have to get a referral to see a specialist.

3. Private Fee-for-Service (PFFS) plans have fixed rates for medical services. 

4. Special Needs Plans (SNPs) are a special type of Medicare Advantage plan that provides specialized benefits, providers, and prescription drug formularies for people who are eligible due to certain chronic conditions or those who are dual-eligibles and qualify for Medicare and Medicaid. In most cases, enrollees must get their care from providers and facilities that are within the Medicare SNP network, with some exceptions.