Part C: Medicare Advantage

What is Medicare Advantage?

Medicare Advantage plans, also known as Medicare Part C, are medical insurance plans administered by private insurance companies. Medicare Advantage (MA) plans are paid a sum of money for each enrollee by the federal government. In turn, the insurance company pays for the cost of care and provides benefits based on the government’s rules.

Who is Eligible for Medicare Advantage?

To be eligible for Medicare Advantage (MA) insurance, you must be:

• Enrolled in Medicare Parts A & B (Original Medicare)
• Live within the Plan’s Service Area

Common Types of MA Plans

Common types of Medicare Advantage plans include:

• Health Maintenance Organizations (HMO)In most HMOs, you must see in-network providers to receive coverage, unless you require emergency medical treatment.
• Preferred Provider Organizations (PPO)In a PPO you can see any provider, but you generally pay more when seeing out-of-network providers.
• Private-Fee-For-Service (PFFS)Most PFFS plans have provider networks. You may pay less for your care when using in-network providers or facilities. All PFFS plans also must cover out-of-network care, but you may pay a higher cost.

You may also see these plans:

• Special Needs Plans (SNP)SNPs are designed to meet specific care needs, and you can only join a SNP if you fit the special needs category the plan serves. SNPs may provide care and coverage coordination services not offered by other types of Medicare Advantage Plan.
• Dual Special Needs Plans (DSNP) DSNPs are designed for Medicare beneficiaries who also qualify for Medicaid. In order for services to be covered under the plan, the provider must accept both Medicare and Medicaid. DSNPs may have either a PPO or HMO network.

What are Medicare Advantage Costs?

Before you enroll in an Advantage plan, you will want to find out the costs associated with these types of plans. Because these plans are tailored by the insurance company and geographic region, below you will see what is common.

Premiums

Many of the Advantage plans available are either low or no-cost. Traditionally HMO advantage plans will carry a $0 per month premium, while PPO advantage plans will sometimes have a monthly premium. Because medical costs vary from area to area, these premiums are fully dependent on what will be available in your area.

Deductibles

Very few Advantage plans have an annual deductible for medical and hospital costs. However, many Advantage plans will have a deductible for higher-tiered prescription drugs.

Copays and Coinsurances

For each medicare advantage plan, you’ll have a Summary of Benefits or a Benefit Highlight sheet that lists the copays and coinsurances for each service you might expect.

It will typically looks something like this:

These Summary of Benefits and Benefit Highlight documents are imperative to your understanding of what to expect to pay for various services on each plan.