Medicare Part C

Information on Advantage plans

Medicare Advantage plans are provided by private insurance companies approved by Medicare. These plans are also known as Medicare Part C. By law, every Medicare Advantage plan must include coverage for everything that Medicare Parts A and B, often called Original Medicare, cover. That means they include the same hospital and outpatient services. But Medicare Advantage plans may also cover more than Original Medicare.

You may be wondering which is the better choice: sign up for a Medicare Advantage plan or Original Medicare. There isn’t a simple answer because Medicare Advantage plans have key features that many people find attractive and other characteristics that may not match with your personal preferences and/or lifestyle.

Medicare Advantage plans must offer at least the same level of coverage as Medicare Part A and Part B and many plans offer added benefits. These may include coverage for routine vision care, hearing aids, routine dental care, prescription drug coverage, and fitness center membership.

Medicare Advantage plans may cost you less

If you enroll in a Medicare Advantage plan, you continue to pay your Medicare Part B premium and you may pay an additional premium. The insurer determines the Medicare Advantage plan’s premium, which can vary from one Medicare Advantage plan to another. Some Medicare Advantage plans may have premiums as low as $0.

Your cost sharing may also be less under Medicare Advantage. For, example, if you visit a primary care physician under Medicare Advantage, you may pay a copayment of $10. However, if you visit a primary care physician under Original Medicare, you may have a coinsurance of 20%, which could be more than $10.

Also, a Medicare Advantage plan limits your maximum out-of-pocket expense. Once you have spent that maximum, you pay nothing for covered medical services for the remainder of the year. Original Medicare does not provide a maximum out-of-pocket cap, so your potential expenses are limitless.

Often a Medicare Advantage plan can be less expensive than comparable coverage you would receive if you stayed with Original Medicare. To get all the benefits of Medicare Advantage with Original Medicare, you would also need to enroll in a stand-alone Medicare Part D Prescription Drug Plan as well as a Medicare Supplement plan.

What does Medicare Advantage cover?

Medicare Advantage plans can serve as your “one-stop” center for all your health and prescription drug coverage needs.
Most Medicare Advantage plans combine medical and Part D prescription drug coverage. Many also coordinate the delivery of added benefits, such as vision, dental, and hearing care. You may prefer the convenience of working with one plan administrator.

While plans vary, some additional benefits of Medicare Advantage plans include:

• Dental coverage
• Vision coverage
• Hearing coverage
• Fitness club membership

Some plans also include prescription drug coverage.

So, a well-chosen Medicare Advantage plan can come with all the coverage you get with Medicare Parts A, B and D. The additional coverage beyond what is offered by the other parts of Medicare is like the icing on the Medicare cake.

What does choosing Medicare Advantage mean for your health care costs?

The costs may differ from the costs you pay with Original Medicare. Here are some of the main differences. 

Premiums

After you choose a Medicare Advantage plan, you’ll continue to pay a monthly Part B premium to Medicare. And you’ll sometimes pay a premium to the company that provides your plan. But there are some Medicare Advantage plans that don’t charge an additional premium.

Deductibles

While Original Medicare has standard deductibles, they can vary among Medicare Advantage plans. And some plans don’t require you to pay a deductible at all.

Copayments

You may pay a smaller copayment – a set amount you pay for care – with Medicare Advantage for a doctor visit than they would under Original Medicare.

Firm limit on how much you pay for care

What happens if an unforeseen event or illness causes you to need a lot of medical care? Medicare Advantage plans come with a firm limit on how much you pay for covered medical care every year. That means once you’ve hit your limit for the year, you don’t pay any additional costs on covered medical services. Original Medicare doesn’t include this limit.

How do Medicare Advantage plans provide extra benefits at a reasonable price?

Medicare Advantage plans harness the power of care networks. These are groups of doctors and other health care professionals who contract with your plan. These networks help keep costs down. It also means your care may not be covered if you go outside your plan’s network. So before you sign up, make sure your favorite doctors are in a plan’s network.

It’s also important to remember that not all plans are alike. Two of the most common types are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). 

What’s the difference between an HMO and PPO plan?

Medicare Advantage HMO plans generally require you to stay within the network. And you may need to get referrals to see specialists. But, there are exceptions for emergency care or out-of-area urgent care. 

Medicare Advantage PPO plans generally have higher monthly premiums than HMO plans. But you have more flexibility to see doctors without a referral. And you may see health care providers outside your plan’s network. You usually pay more if you do. 

Traveling with Medicare Advantage

If you travel regularly, make sure you’ll be covered if you need care while on the road. Medicare Advantage plans tend to have a service area. This means that particular plans are only available to people who live in specific areas. And networks of health care professionals may be restricted to the plan’s geographic area. But there are exceptions.

Some Medicare Advantage plans focus on more than one region. So if you summer in New England but winter in Florida, there might be a plan out there for you. Be sure to shop around to make sure there are in-network doctors in both places. Just because you travel regularly doesn’t necessarily mean Medicare Advantage isn’t for you.

Some perks of MA plans

Lifestyle coaching programs: talk with a health coach about how to reach goals like managing stress better, quitting smoking or improving your diet.

A multidisciplinary care management team: connect to the right resources, coordinate your benefits and ensure better orchestration of care.

Online tools and resources: look up guides to make healthy decisions and manage conditions. 

The three C’s of Medicare Advantage: cost, coverage and convenience

Medicare Advantage brings together the benefits of other parts of Medicare (plus a few added benefits) under a single plan. So it helps you with the three C’s: cost, coverage and convenience.

However, Medicare Advantage plans aren’t necessarily for everyone. You’ll need to shop around. See if a Medicare Advantage plan that fits your goals is available in your area. 

Cons of Medicare Advantage plans

-Medicare Advantage plans may limit your freedom of choice in health care providers
-With the federally administered Medicare program, you can generally go to any doctor or facility that accepts Medicare and receive the same level of Medicare benefits for covered services. In contrast, Medicare Advantage plans are more restricted in terms of their provider networks. If you go out of network, your plan may not cover your medical costs, or your costs may not apply to your out of pocket maximum.

Medicare Advantage plans’ coverage for some services and procedures may require doctor’s referral and plan authorizations.

Medicare Advantage plans try to prevent the misuse or overuse of health care through various means. This might include prior authorization for hospital stays, home health care, medical equipment, and certain complicated procedures. Medicare Advantage plans often also require your primary care doctor’s referral to see specialists before they will pay for services.

Medicare Advantage plans have specific service areas

Most Medicare Advantage plans have regional (rather than nationwide) networks of participating providers. To enroll, you must reside in the Medicare Advantage plan’s service area at least 6 months of the year. If you divide your time between homes located in different areas, this requirement may be difficult to meet.

The bottom line is that Medicare Advantage plans may provide more affordable coverage than you would receive otherwise. The trade-off is that you have to follow the Medicare Advantage plan’s rules to receive payment for covered services.