MEDICARE ADVANTAGE PART C
A Medicare Advantage Plan is another way to get your Medicare Part A and Part B coverage.
Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-
approved private companies that must follow rules set by Medicare. These plans set a limit on
what you’ll have to pay out-of-pocket each year for covered services. Some plans offer non-
emergency coverage out of network, but typically at a higher cost. In most cases, you’ll need to
use health care providers who participate in the plan’s network and most Medicare Advantage
Plans include drug coverage (Part D).
To join a Medicare Advantage Plan, you must:
- Have Original Medicare Part A and Part B.
- Live in the plan’s service area.
- Be a United States citizen or lawfully present in the United States.
There are different kinds of Medicare Advantage Plans with different benefits. Two of the most common are Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO) plans. Medicare Advantage Plans provide all your Original Medicare Part A and Part B benefits, excluding clinical trials, hospice services, but must cover all emergency and urgent care, and almost all medically necessary services Original Medicare covers. If you’re in a Medicare Advantage Plan, Original Medicare will still help cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.
Most Medicare Advantage Plans offer coverage for things Original Medicare doesn’t cover, like fitness programs (like gym memberships or discounts) and some vision, hearing, and dental services. Plans can also choose to cover even more benefits. For example, some
plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness such as healthy food cards. Plans can also tailor their benefit packages to offer additional benefits to certain chronically ill enrollees. These plan packages provide benefits customized to treat specific conditions.
You can join a Medicare Advantage Plan even if you have a pre-existing condition. For example, If you have End Stage Renal Disease (ESRD), you can choose either Original Medicare or a Medicare Advantage Plan when deciding how to get Medicare coverage. You can enroll in a Medicare Advantage Plan during Open Enrollment (October 15 – December 7). Your plan coverage will start January 1st of the following year. Ask your Medicare agent for more details regarding ESRD.
Most Medicare Advantage Plans include Medicare drug coverage (Part D). In certain types of plans that don’t include Medicare drug coverage (like Medical Savings Account Plans and some Private-Fee-for-Service Plans), you can join a separate Medicare drug plan. However, if you join a Medicare Advantage Health Maintenance Organization (HMO) or Preferred Provider Organization Plan (PPO) which doesn’t cover drugs, you can’t join a separate Medicare drug plan.
When thinking of changing any group health insurance plan, talk to your employer, union, or other benefits administrator first about their rules before you join a new plan such as a Medicare Advantage Plan. You can only be in one Medicare Advantage Plan at a time.
What does a Medicare Advantage plan cost?
- Most Medicare Advantage plans have low to $0 premiums.
- But you must continue to pay your Original Medicare Part B premium ($170.10 in 2022) and Part A premium (if you do not have a premium-free Part A).
- Medicare Advantage plans, only cover one person. Spouses need a separate plan.
- There are typically copayments or coinsurance for each visit or service, but it cannot be more than what Original Medicare would charge.
- Medicare Advantage plans have networks and if you go outside those networks, except in an emergency, you may have to pay more or not be covered at all.
- Some plans offer extra benefits and there may be a cost associated with these benefits, such as copays for eyeglasses or hearing aids.
- Plans have a maximum out of pocket for medical services and may have a separate deductible for prescription drugs depending on the type of drug and what Tier category it falls in.
- You can ask your plan, in advance if it covers a service, drug or supply. This is called an “organization determination”. If your plan denies coverage, you have the right to appeal.
- If the plan provider refers you to a provider outside the network without getting an organization determination first, this is call “plan directed care” and in most cases, you won’t have to pay more than the plan’s usual cost sharing.
There are multiple types of Medicare Advantage Plans and different times you can join, switch, drop or make changes to your current plan. Ask your Medicare Agent to review all the options.