Medicare Advantage (Part C) Plans
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: January 1, 2021
What You Should Know
- 1 Medicare Advantage plans cover the same care and services as Original Medicare, but many also include coverage for services like dental, vision, and auditory care.
- 2 Medicare Advantage plans are underwritten by private insurance companies, and consist of multiple different plan types, including HMO, PPO, PFFS, and SNP plans.
- 3 In general, anyone who is eligible to enroll in Medicare Parts A and B is eligible to sign up for a Medicare Advantage plan.
- 4 Unlike Original Medicare plans, which have fixed costs, Medicare Advantage plans’ prices for premiums, deductibles, and coinsurance vary based on the provider and coverage.
Medicare is the federal healthcare plan for individuals 65 years of age and older, and certain individuals younger than 65 with disabilities. Also known as Original Medicare, this program consists of two parts:
- Medicare Part A (Hospital insurance): Covers inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home healthcare
- Medicare Part B (Medical insurance): Covers outpatient care, preventative care, certain doctor’s services, and medical supplies
Medicare Part C, also known as Medicare Advantage, exists as an alternative way for Medicare-eligible individuals to get the benefits of Medicare Parts A and B. Medicare Advantage plans are underwritten by private insurance companies, and while they must include the same care and services offered by Medicare Parts A and B, they also typically include coverage for additional services, like vision, dental, and auditory care.
Coverage for prescription drugs is provided by Medicare Part D, in which private insurers offer prescription drug plans to individuals covered by Medicare.
What is Medicare Advantage?
Medicare Advantage is an alternative way for Medicare-eligible individuals to get healthcare coverage through private insurance companies. While Medicare Advantage plans include the same type of hospital and medical insurance provided by Medicare Parts A and B, many also often include coverage for services not included in Original Medicare, like vision, dental, and auditory care. They also are not subject to the deductibles associate with Original Medicare.
Prescription drug coverage varies based on the individual Medicare Advantage plan. Some plans include prescription drug coverage. For plans that do not, customers can obtain prescription drug coverage through Medicare Part D.
With Medicare Advantage, there are a few different types of plans available.The exact availability of plans depends on your health insurance provider and geographic location.
Types of Medicare Advantage plans include:
- Health Maintenance Organization (HMO): Users get access to certain doctors and hospitals within the provider’s network who have agreed to give HMO customers lower rates. Visits to non-network providers will likely not be covered, resulting in out-of-pocket fees for individuals. Some Medicare Advantage HMO plans make out-of-network exceptions for emergency care, out-of-area urgent care, and out-of-area dialysis.
- Preferred Provider Organization (PPO): These plans also use a network of approved providers, but give customers more flexibility to go outside of that network for care. PPO plans may also cover some of the cost of seeing a non-network provider, but they may have higher premiums, as well as a deductible.
- Private Fee for Service (PFFS): This plan type offers customers more flexibility, as it does not require primary care doctors or referrals. In a PFFS plan, the insurance company determines how much it pays doctors and healthcare providers, and how much the customer pays, based on limits set by the Centers for Medicare and Medicaid Services. (CMS). Therefore, some doctors may choose to not accept patients with a PFFS plan.
- Special Needs Plans (SNP): Designed specifically for people with specific diseases or characteristics, this plan allows users to tailor their benefits, provider choices, and drug formularies to best meet their needs. Eligibility is restricted compared to HMO and PPO plans, and the availability of Medicare SNPs varies by location. These plans also encompass dual eligible individuals who have both Medicare and Medicaid.
- Medicare Savings Account (MSA): Similar to a Health Savings Account (HSA), this plan type combines a high-deductible insurance plan with a medical savings account, funded by Medicare, that customers can use to pay their healthcare costs. Once customers reach their deductible, the plan pays for Medicare-covered services. However, if customers run out of money in their MSA before reaching their deductible, they must pay the difference for healthcare costs out-of-pocket.
Advantages of Medicare Advantage
As of 2019, approximately 22 million people – one-third of all Medicare beneficiaries — were enrolled in a Medicare Advantage plan. These plans are very popular for a number of reasons:
- Medicare Advantage plans include Medicare Part A and B coverage, but also typically include coverage for vision, dental, and auditory care, as well as prescription drug coverage.
- Unlike Original Medicare, these plans have out-of-pocket spending caps. Out-of-pocket costs are also fixed, regardless of the cost of the service provided.
- Because Medicare Advantage plans use co-payments instead of coinsurance, customers have set prices for different types of care and services they may use.
- Some Medicare Advantage plans include coverage for emergency care outside the U.S. Original Medicare plans do not cover care, including emergency services, rendered outside the U.S.
- These plans do not have to pay the deductibles associated with original Medicare.
- There are a number of cost effective plans as low as $0 premium.
Disadvantages of Medicare Advantage
Medicare Advantage plans have a number of benefits, but that doesn’t mean they are right for everyone. Here are some downsides to consider when deciding if a Medicare Advantage plan is the best option for you:
- Premium amounts for Medicare Advantage plans vary. Premium amounts for Original Medicare are standard, and individuals who meet certain criteria may not have to pay any premium for Medicare Part A.
- The deductible amounts for Medicare Advantage plans vary by plan, and in some cases, may be higher than the fixed deductibles for Medicare Parts A and B, which are adjusted annually.
- Because most Medicare Advantage plans rely on provider networks, patient choice is more limited than it is with Original Medicare, which is accepted by more doctors, hospitals, and healthcare providers.
Who is eligible for Medicare Advantage?
Generally speaking, the same eligibility guidelines that apply to Original Medicare apply to Medicare Advantage. Individuals who are 65 and older, and individuals who are younger than 65, but have certain disabilities, are considered eligible for Original Medicare.
If you already have Medicare Part A and Medicare Part B, you are most likely eligible for Medicare Part C. If you are unsure about your eligibility, you can use Medicare’s online tool to check your status.
Starting with the 2020 Open Enrollment period, which runs from October 15 to December 7, 2020, individuals with End Stage Renal Disease (ESRD) are eligible to enroll in Medicare Advantage plans, with coverage taking effect in January 2021. Previously, individuals with this condition were only eligible for Special Needs Plans.
Individuals who have Medicare Supplemental Insurance, also known as Medigap, are not eligible for Medicare Advantage plans unless they drop their Medigap coverage.
Eligibility for specific Medicare Advantage plans will vary based on the individual company and geographic location.
How much does a Medicare Advantage plan cost?
The simple answer to this question is, it depends. Unlike Original Medicare, which has fixed costs for premiums, deductibles, and coinsurance, the costs associated with Medicare Advantage vary based on the insurance provider and specific plan.
Deductible prices can vary widely with Medicare Advantage plans. Some Medicare Advantage plans have no deductibles (although they may offset this with higher premiums), while others have deductibles that may be higher or lower than the standard Original Medicare deductible.
Another consideration is whether your Medicare Advantage plan uses coinsurance or copayments for out-of-pocket costs. Copayments mean you will know upfront how much you are expected to pay for services after you meet your deductible. Coinsurance for payments beyond your deductible means the out-of-pocket amount is dependent upon the overall cost of the service provided. All Original Medicare plans use coinsurance to determine out-of-pocket payments.
There is an out-of-pocket spending cap with Medicare Advantage plans, meaning that once you reach your out-of-pocket limit for the year, all other costs for Part A and Part B services are 100% covered. Original Medicare has no out-of-pocket spending cap.
How do I enroll in a Medicare Advantage plan?
In order to enroll in a Medicare Advantage plan, you must first be enrolled in Original Medicare Parts A and B. To be eligible to enroll in Original Medicare, you must be:
- An individual turning 65: The three months prior to turning 65, the month you turn 65, and the three months after you turn 65 is considered the Initial Enrollment Period (IEP), OR
- An individual under 65 with a disability and receiving disability payments through Social Security or the Railroad Retirement Board.
For most people, Medicare Advantage plan enrollment occurs at the same time as your Initial Enrollment Period to Original Medicare. That said, there are additional enrollment periods throughout the year to note:
- Annual Enrollment Period (October 15-December 7):During this period, a person on Original Medicare with no Advantage plan can enroll in an Advantage plan. Additionally, individuals who are currently enrolled in an Advantage plan can switch to another Advantage plan or return to Original Medicare.
- Medicare Advantage Open Enrollment Period (January 1-March 31): During this period, those currently enrolled in a Medicare Advantage plan can switch plans or return to Original Medicare. Those on Original Medicare cannot join an Advantage during this period.
- General Enrollment Period (April 1-June 30):This period is for enrollment in Original Medicare for those who missed their Initial Enrollment Period (IEP). Enrollment in Medicare Advantage can coordinate with this period.
- Special Enrollment Period (varies): For those who move or lose other insurance coverage, there are special enrollment periods that allow you to make changes to your plan. The time period and changes allowed vary by situation.
If you do not sign up for Medicare benefits during these time frames, you may face penalties. Exceptions are made for people who are actively employed and receiving health insurance from their employer, or are involved in qualified overseas volunteerism. If you are approaching age 65 and are still working, consult with your employer to find out if your coverage will continue, or if you will need to switch to a Medicare plan. If your employment situation changes, you can join Original Medicare or Medicare Advantage during a special enrollment period.
Because Medicare Advantage plans are offered by individual insurance companies, the enrollment processes will differ depending on the carrier. Below, we outline the general steps you can take to enroll in a Medicare Advantage plan:
- Visit Medicare’s Plan Finder to find available plans in your area.
- Comparison shop plans based on your needs and budget.
- When you select the plan in which you would like to enroll, follow the provider’s instructions for completing an enrollment application. Many plans will allow you to fill out the application online, although all plans are required to offer an option for a paper enrollment form.
When you sign up for a Medicare Advantage plan, you will need to provide your Medicare number, as well as the date your Medicare Part A and Part B coverage began.
Who should get a Medicare Advantage plan?
There is no specific rule for who should enroll in a Medicare Advantage plan. Rather, the choice between Original Medicare and a Medicare Advantage plan depends on a number of factors unique to each individual. These factors include:
- Costs: This includes your premiums, deductibles, and out-of-pocket costs
- Coverage: What types of services do you need, and which type of plan provides the most robust coverage?
- Other coverage: Do you have coverage provided by an employer, through a spouse’s insurance, or through a supplemental program like Medigap or an Indian Health or Tribal Health Program?
- Prescription drugs: Do you already have a prescription drug plan, or do you need to join a Medicare Prescription Drug Plan? What types of prescription drugs do you use, and are they covered by a plan’s formulary?
- Doctor and hospital choice: Are your current doctors considered in-network or out-of-network for a particular Medicare Advantage plan? How much flexibility do you want in which doctors and hospitals you can visit?
- Quality of care: Are you satisfied with the care you receive from your current providers, or do you want flexibility to seek care from other providers?
- Travel: Do you frequently travel outside the U.S.? Original Medicare does not cover care provided outside the U.S., including emergency care. Not all Medicare Advantage plans cover care outside the U.S., but some do.
It is always possible to switch Medicare Advantage plans, or switch to Original Medicare, during enrollment periods, if you find that your current plan does not meet your needs.
Highly-rated Medicare Advantage Plans
|Aetna||Aetna’s Medicare Advantage offerings include HMO, HMO-PPS, PPO, and SNP plans. Most plans include dental, vision, and hearing care, as well as extra benefits like prescription home delivery, SilverSneakers® fitness membership, and 24/7 teleaccess to nurses. In the 2020 CMS Five-Star Ratings, Aetna plans received an overall weight score of 4.3 out of five stars.||All 50 states|
|Cigna||Cigna’s Medicare Advantage plans include a variety of programs and services, including behavioral health, case management preventative care, discounts for health and wellness programs, and more. They also offer several low-premium plans. Cigna customers benefit from a holistic, team-based approach to healthcare, in which Cigna’s case managers and pharmacists work closely with customers’ doctors and specialists to create successful healthcare and treatment plans. Exact plan types vary by location.||AL, AR, AZ, CO, DE, FL, GA, IL, KS, MD, MO, MS, NC, NJ, PA, SC, TN, TX, District of Columbia|
|Highmark||Although Highmark’s Medicare Advantage availability is limited to a few Mid-Atlantic states, for customers living in that region, it is an option worth considering. Customers can choose between an HMO or PPO plan. All Highmark plans come with exclusive benefits like on-call registered nurses for 24/7 care, a once-a-year house call from a licensed healthcare provider, as well as a home visit program for those dealing with serious medical conditions, and SilverSneakers® fitness memberships.||DE, PA, WV|
|Humana||Humana is one of the most flexible Medicare Advantage providers. They offer several Medicare Advantage options, including HMO, PPO, PFFS, and SNP plans, which meet a range of customer needs for affordability, flexibility, and scope of care. Many Humana plans include routine dental, vision, and hearing care. Customers can also take advantage of Humana’s pharmacy plan for discounts and mail-delivery service.||All 50 states, District of Columbia, and Puerto Rico|
|Kaiser Permanente||Kaiser Permanente’s highly-rated Medicare Advantage HMO plans are available mainly to customers on the West Coast, although they do offer plans in some Mid-Atlantic and Southern states as well. A number of plans have $0 co-pays for preventive care services, and prescription drug coverage is included with all plans. Customers can choose to add dental, hearing, and vision benefits. Kaiser Permanente boasts an extensive network of doctors and specialists.||CA, CO, GA, HI, MD, OR, VA, WA, District of Columbia|
|UnitedHealthcare||UnitedHealthcare offers its Medicare Advantage members a variety of benefits, including $0 co-pays on primary care doctor visits, as well as common prescriptions; free preventive dental and vision exams, 24/7 virtual telehealth visits, and gym memberships. UnitedHealthcare offers HMO and SNP plans, as well as supplemental insurance and Medicare Part D prescription drug coverage.||All 50 states, District of Columbia, and U.S. territories|
- Sources [-]
https://www.medicare.gov/ Last accessed December 2020
https://www.medicare.gov/what-medicare-covers/what-part-a-covers Last accessed December 2020
https://www.medicare.gov/what-medicare-covers/what-part-b-covers Last accessed December 2020
https://www.medicare.gov/drug-coverage-part-d Last accessed December 2020
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans Last accessed December 2020
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/preferred-provider-organization-ppo Last accessed December 2020
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/private-fee-for-service-pffs-plans Last accessed December 2020
https://www.cms.gov/ Last accessed December 2020
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp Last accessed December 2020
https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance Last accessed December 2020
https://www.medicare.gov/your-medicare-costs/part-a-costs Last accessed December 2020
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html#:~:text=Generally%2C%20Medicare%20is%20available%20for,Part%20B%20(Medicare%20Insurance). Last accessed December 2020
https://www.medicare.gov/eligibilitypremiumcalc/ Last accessed December 2020
https://www.medicare.gov/blog/medicare-coverage-for-end-stage-renal-disease Last accessed December 2020
https://www.aarp.org/health/medicare-qa-tool/do-i-enroll-in-medicare-age-65-even-if-still-working/ Last accessed December 2020
https://www.medicare.gov/plan-compare/#/?lang=en Last accessed December 2020
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.