Medicare Advantage plans are health plans offered under the Medicare Part C program. Available through private insurance companies approved by Medicare, these plans offer another way to get your Medicare Part A and Part B benefits.
Medicare Advantage plans are required to cover all benefits offered under Original Medicare, Part A and Part B (with the exception of hospice care, which is still covered through Part A of the government-run program). This means that regardless of which Medicare Advantage plan you enroll in, you’ll get the same hospital and medical benefits you’d have under Original Medicare.
In addition, many Medicare Advantage plans offer benefits that Original Medicare doesn’t cover, including:
One major benefit of Medicare Advantage is that you have the option of getting your prescription drug benefits included in the same plan. Unlike Original Medicare, where prescription drug coverage is available through a separate, stand-alone plan, Medicare Advantage Prescription Drug plans give you the convenience of having your Part A, Part B, and Part D benefits administered through a single plan. Keep in mind that not every Medicare Advantage plan offers prescription drug benefits, so always double-check with the specific plan you’re considering before enrolling.
Eligibility for Medicare Advantage plans
You’re eligible for Medicare Part C coverage if:
- You’re enrolled in Medicare Part A and Part B.
- You live in the service area of a Medicare Advantage plan.
- You don’t have end-stage renal disease (with some exceptions).
Types of Medicare Advantage plans
Medicare Advantage plans deliver benefits through a number of different options. Not every plan type is available in every area, and benefits and costs vary by plan and location. Here are some of the plan types that may be available:
- HMO: A Health Maintenance Organization (HMO) plan has a network of doctors, hospitals, and providers that you must use to be covered by the plan. You’re typically not covered if you go out of network for care (except for emergency or urgent care). HMOs require that you choose a primary care physician to coordinate your care; if you need to see a specialist, you must get a referral from your primary care doctor first.
- PPO*: A Preferred Provider Organization (PPO) plan also has a provider network, and your costs are lower if you use doctors and hospitals in its preferred provider network. However, unlike HMOs, you also have the flexibility to use non-network doctors, although your cost sharing may be higher. You do not need to select a primary care physician or need referrals for specialist care.
- HMO POS: Some Health Maintenance Organization plans have a Point-of-Service (POS) option. These plans work similarly to traditional HMO plans, which have a network of providers you must use to receive medical care. However, HMO POS plans may also allow you to go out-of-network for certain services, usually at a higher cost sharing.
- SNP: Special Needs Plans (SNPs) limit enrollment to beneficiaries who meet certain eligibility criteria. There are three types – Dual-Eligible SNPs target those with Medicare and Medicaid coverage; Chronic-Condition SNPs target those with certain chronic and disabling conditions; and Institutional SNPs target those who live in institutions, such as nursing homes. SNPs cater benefits, provider networks, and formularies to meet the unique needs of its members.
- MSA: A Medical Savings Account plan combines a high-deductible health plan with a medical savings account plan. The MSA plan deposits a certain amount of money into a medical savings account every year, which you can use to pay for qualifying medical expenses until you reach the plan’s high deductible. Once you reach the annual deductible, the plan begins to cover costs.
- PFFS: A Private Fee-for-Service (PFFS) plan lets you use any doctor that accepts the plan’s payment terms and conditions and agree to treat you. There’s no guarantee that your doctor or hospital will accept the plan, and the provider must contract with the plan on a service-by-service basis. Some PFFS plans have networks of providers that will always agree to treat you.
Compare Medicare Advantage plans
As you consider the type of coverage that may work best for your needs, here are some things to keep in mind. Medicare Advantage plan availability may vary by state and location. Premiums for the same plan can even vary among counties within the same state. Because of this, it is important to compare all available plan options in your area before enrolling in a Medicare Advantage plan. Here are a few other factors to consider:
- What are the costs associated with your coverage — Some Medicare Advantage plans may offer premiums as low as $0. However, keep in mind that even if your service area offers a plan with a $0 premium, you’ll still be responsible for other costs, which may include deductibles, copayments, and coinsurance. You’ll also need to keep paying your Part B premium.
- Whether the plan has drug coverage — Most, but not all, Medicare Advantage plans offer prescription drug coverage; these plans are also known as Medicare Advantage Prescription Drug plans, or MAPDs. However, if you already have existing creditable prescription drug coverage (insurance that is as good as the Part D benefit), you may be interested in a plan without prescription coverage. If you’re enrolling in a Medicare Advantage plan that covers medications, always double-check that your prescriptions are covered under the plan’s formulary (list of covered drugs), since plans vary when it comes to covered medications. Keep in mind that the formulary may change at any time; the Medicare plan will notify you if needed.
- What additional benefits are offered – As mentioned, Medicare Advantage plans will sometimes offer benefits beyond what is covered in Original Medicare. Since coverage may vary by plan, it’s important to check with the individual plan if there’s a specific benefit, such as routine vision coverage, that you’re interested in.
You can compare Medicare Advantage plan options in your area by using the Medicare Advantage plan comparison tool on this page. The tool makes it easy to customize your search based on your health and prescription drug needs. Would you prefer to speak to someone about your coverage needs? Feel free to call the phone number on this page to reach a licensed insurance agent.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.