Medicare Part C (Medicare Advantage)

Medicare Part C (Medicare Advantage)

Medicare Part C (Medicare Advantage)

A Medicare Advantage plan (like an HMO or PPO) is a Medicare health coverage option you may have when you qualify for Medicare due to age or disability. Medicare Advantage plans, sometimes called “Part C” or “MA” plans, are offered by private companies approved by Medicare.

If you join a Medicare Advantage plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. In MA plan types, you are covered for emergency and urgent care. Medicare Advantage plans must cover all of the services that Original Medicare covers, except hospice care. Original Medicare covers hospice care even if you are in a Medicare Advantage plan.

Medicare Advantage plans may offer additional coverage, such as vision, hearing, dental, and/or health and wellness programs. Many include Medicare prescription drug coverage. In addition to your Part B premium, you usually pay one monthly premium for the services provided.

Who Can Enroll in Medicare Part C?

You can generally join a Medicare Advantage plan if you meet these conditions:

  • You have Part A and Part B.
  • You live in the service area of the plan.

How Medicare Part C Plans Work

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage plans. These companies must follow rules set by Medicare. However, each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan’s network).

Types of Medicare Advantage Plans

Medicare Advantage plans include:

  • Health Maintenance Organizations (HMO)
  • Preferred Provider Organizations (PPO)
  • Private Fee-for-Service Plans (PFFS)
  • Point of Service (POS) Plans
  • Provider Sponsored Organizations (PSO)
  • Medical Savings Account (MSA) Plans
  • Special Needs Plans (SNP)

Health Maintenance Organization (HMO) - A type of Medicare Advantage plan that is available in some areas of the country. HMO plans must cover all Medicare Part A and Part B health care benefits. Some HMOs cover extra benefits, like additional days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals in the plan’s network of providers, except in an emergency. Your costs may be lower than in Original Medicare.

Preferred Provider Organization (PPO) - A type of Medicare Advantage Plan in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Private Fee-for-Service Plan (PFFS) - A type of Medicare Advantage plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have additional benefits Original Medicare doesn’t cover.

Medical Savings Account (MSA)  - Medicare MSA Plans have two parts: a high deductible health plan and a bank account. Medicare gives the plan an amount each year for your health care, and the plan deposits a portion of this money into your account. The amount deposited is less than your deductible amount, so you will have to pay out-of-pocket before your coverage begins.

Point of Service (POS) Plan - An HMO option that lets you use doctors and hospitals outside the plan for an additional cost.

Provider Sponsored Organization (PSO) – PSO plans are run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan.

Special Needs Plan (SNP)- A type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.

How Much Do Medicare Advantage Plans Cost?
The out-of-pocket costs for a Medicare Advantage plan vary widely, and depend on the following:

  • Whether the plan charges a monthly premium in addition to your Part B premium.
  • Whether the plan pays any of the monthly Part B premium.
  • Whether the plan has a yearly deductible or any additional deductibles.
  • How much you pay for each visit or service (copayments).
  • The type of health care services you need and how often you get them.
  • Whether you follow the plan's rules, like using network providers.
  • Whether you need extra coverage and what the plan charges for it.
  • Whether the plan has a yearly limit on your out-of-pocket costs for all medical services.

If you have limited income and resources, you may qualify for the following:

  • Extra Help paying for your Part D premium and other prescription drug coverage costs.
  • Help from your state to pay your Part B premium.

For More Information:

  • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week.
  • Visit www.medicare.gov/Publications/Pubs/pdf/10126.pdf to view the brochure, “Get Help With Your Medicare Costs: Getting Started.” You can learn more by reading Medicare & You, the official government handbook about Medicare. You will need the free Adobe® Reader® software to download the files.

Download Medicare & You

How To Enroll In and Switch Medicare Advantage Plans
When Can You Join, Switch, or Drop a Medicare Advantage Plan?

You can join, switch, or drop a Medicare Advantage plan at these times:

  • When you first become eligible for Medicare (the 7-month initial enrollment period begins 3 months before you turn age 65, includes the month you turn 65, and ends 3 months after the month you turn 65).
  • If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of receiving disability benefits from Social Security or the Railroad Retirement Board. You will have another chance to join 3 months before the month you turn 65 to 3 months after the month you turn 65.
  • During the Annual Election Period (AEP) between October 15–December 7. Your coverage will begin on January 1 of the following year. If you have ESRD, you may enroll in a Medicare Advantage plan during AEP.
  • During the Medicare Advantage Open Enrollment Period (MA-OEP), from January 1-March 31. During this period, you may make one change. You can switch from one Medicare Advantage plan (with or without prescription drug coverage) to another Medicare Advantage plan (with or without prescription drug coverage.). You can drop your MA plan and revert to Original Medicare, and enroll in a stand-alone Prescription Drug Plan at that time, as well.
  • During the 5-Star Special Enrollment Period between December 8 and November 30. If you are already enrolled in an MA plan and a 5-star rated plan is available in your area, you may switch once from your current plan to the 5-star plan.

In most cases, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop a Medicare Advantage Plan at other times if you qualify for a Special Enrollment Period. Some of these situations include the following:

  • If you move out of your plan’s service area
  • If you qualify for both Medicare and Medicaid
  • If you qualify for Extra Help to pay for your prescription drug costs
  • If you move in or out of an institution (like a nursing home)

You can learn more about Original Medicare and the Medicare program by reading Medicare & You, the official government handbook about Medicare.