Medicare Advantage — also called Medicare Part C — is an alternative way to receive your Medicare benefits. Instead of Original Medicare paying your claims directly, you enroll in a plan offered by a private insurance carrier that has been approved by Medicare. That carrier becomes your primary payor.

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Medicare Advantage plans are required to cover everything Original Medicare covers, and many include additional benefits such as dental, vision, and hearing.

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Most Medicare Advantage plans include prescription drug coverage built in — these are called MAPD plans (Medicare Advantage Prescription Drug Plan). Plans without drug coverage are called MA-Only plans and are less common. They are designed for people who have qualifying drug coverage from another source, most commonly veterans who receive prescription drug benefits through the VA. If you have VA drug coverage and are exploring Medicare Advantage, this distinction may be relevant to your situation — check out or blog, or call us to discuss.

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How Medicare Advantage Plans Work

When you enroll in a Medicare Advantage plan:

• You must first have Medicare Parts A and B

• Your Medicare benefits are delivered through the private carrier's plan

• You typically pay a monthly premium to the carrier — though some plans are available with $0 monthly premiums

• You use the carrier's network of doctors, hospitals, and providers

• You pay copays, coinsurance, and deductibles according to your plan's benefit structure

• Benefits, premiums, and cost-sharing vary by plan

• Your plan has an annual out-of-pocket maximum — once you reach it, the plan covers 100% of covered services for the rest of the year

 

Original Medicare does not have an out-of-pocket maximum, which is one reason many people choose Medicare Advantage. However, while MA plans offer an out-of-pocket maximum, they also utilize provider networks, whereas Original Medicare provides the flexibility to see any provider that accepts Medicare

 

Medicare Advantage Plan Types

• HMO (Health Maintenance Organization) You select a primary care physician who coordinates your care. Referrals are generally required to see specialists. You use in-network providers except in emergencies.

• PPO (Preferred Provider Organization) More flexibility to see providers inside or outside the network, though in-network care costs less. Referrals are generally not required.

• Special Needs Plans (SNPs) Designed for people with specific chronic conditions, dual Medicare/Medicaid eligibility, or institutional care needs. These plans are not available to everyone.

 

Your Plan Can Change Every Year

Medicare Advantage plan benefits are not permanent. Each year during the Annual Enrollment Period (AEP)— October 15 through December 7 — carriers can change premiums, copays, provider networks, drug formularies, and benefits. A plan that works well for you this year may look significantly different next year. Plan members receive an Annual Notice of Change (ANOC) before October 1. If you have a Medicare Advantage plan, you can change your carrier and/or your plan for the coming year.

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This is why an annual plan review matters. If you receive your ANOC and want to consider other options, we can help. If you like your current plan and are comfortable with the changes, you can do nothing and your plan will renew.

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$0 Premium Plans

Some Medicare Advantage plans are available with $0 monthly premiums. These plans offer a different premium structure and cost-sharing balance — and it's important to understand how they work.

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A $0 premium means you pay no monthly premium to the carrier. However, you still pay:

• Your Medicare Part B premium (deducted from Social Security for most people)

• Copays and coinsurance when you use your benefits — for example, a hospital stay, specialist visit, or outpatient procedure

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Is Medicare Advantage Right for You?

Medicare Advantage works well for many people, but it's not the right fit for everyone. Return to our Medicare Plan Options page to learn more. 

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