Medicare Advantage Plans
Leverage the experience at Pro Insurance Resources to weigh your Medicare coverage options.
What is a Medicare Advantage (Part C) Plan?
Medicare Advantage (Part C) plans are a combined alternative to Original Medicare. Offered by private insurance companies approved by Medicare, these plans bundle:
- Part A (hospital)
- Part B (medical)
- Often Part D (prescription drugs)
- Sometimes additional benefits, depending on the plan
When you enroll in a Medicare Advantage plan, your Medicare benefits are managed through the private plan, not through Original Medicare directly. But you're still part of the Medicare program.
Types of Medicare Advantage Plans
- Health Maintenance Organization (HMO)
Must use the plan's network providers (except in emergencies); referrals often required. - Medicare Medical Savings Account (MSA)
Combines a high-deductible plan with a Medicare-funded savings account; usually no defined network. Must purchase a standalone Part D Prescription Drug Plan. - Preferred Provider Organization (PPO)
Plan covers in-network providers, and out-of-network providers at a higher cost; no referrals needed. - Private Fee-for-Service (PFFS)
You can see any Medicare-approved provider who agrees to the plan’s payment terms, which decide how much it will pay providers and how much you will pay. - Special Needs Plan (SNP)
Designed for people with specific health conditions, dual eligibility for Medicare and Medicaid, or those living in certain facilities.
Key Features: Medicare Advantage Plans
Bundled Coverage
Most plans include hospital, medical, and prescription drug coverage in one plan.
Extra Benefits (Varies)
Many plans include other benefits. Varies by carrier and plan, so check plan details.
Cost Predictability
Some plans have lower deductibles or $0 premiums and include annual out-of-pocket maximums, which Original Medicare does not.
Coordinated Care
Many Medicare Advantage plans, such as HMOs or PPOs, operate under managed care models and can provide coordinated care options for beneficiaries. These plans may require you to choose a primary care physician and obtain referrals to see specialists.
Flexibility in Provider Choice (Varies)
Some plans offer flexibility to see out-of-network providers, often for a higher cost. This may allow for continuity of care with current healthcare providers.
Medicare Star Ratings
Plans are rated on a 5-star scale based on quality of care, customer service, and member satisfaction, making it possible to find a highly-rated plan.
Medicare Advantage Plan Types
| Plan Type | Provider Access | Referrals Needed? | Out-of-Network Coverage | Key Features | Includes Part D? |
|---|---|---|---|---|---|
| HMO (Health Maintenance Organization) | Must use doctors and hospitals in the plan's network | Yes, for most specialists | No, unless emergency or prior approval | Lower premiums, limited network, coordinated care | Usually yes |
| PPO (Preferred Provider Organization) | Can use in-network or out-of-network providers | No | Yes, but you'll pay more out of network | More flexibility, higher premiums | Usually yes |
| PFFS (Private Fee-for-Service) | You can see any Medicare-approved provider who agrees to the plan’s payment terms | No | Yes, but provider must accept plan’s terms each time | No network restrictions, but providers can refuse to accept the plan | Sometimes |
*Must be purchased in addition to Original Medicare (Parts A and B)
Medigap + Original Medicare = more flexibility, fewer surprises
Medicare Advantage = bundled benefits, lower upfront cost [link]
Choosing a Medicare Advantage Plan
When selecting a Medicare Advantage plan, it's essential to consider your individual healthcare needs, including additional benefits/coverage, prescription drug coverage, provider networks, and out-of-pocket expenses. Here are some factors to evaluate:
- Costs: Compare the monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums for each Medicare Advantage plan for your desired coverage.
- Coverage Needs: Review the plan's benefits to ensure they align with your healthcare needs, including coverage for prescription drugs and other services.
- Prior Authorization: Consider requirements for prior authorization (PA). Most Advantage plans require PA for specialist care, diagnostic imaging, etc. Be sure you understand these guidelines to avoid delaying care.
- Plan Ratings: Plans are officially rated on a 5-star scale based on quality of care, customer service, and member satisfaction. Use plan ratings (found in Medicare.gov’s plan finder tool) to gauge the quality and performance of the plan.
- Prescription Drug Coverage: Ensure your prescription drugs are included in the plan’s formulary (list of covered medications), and that the plan’s preferred pharmacies are convenient for you.
- Provider Network: Determine if the plan’s network includes, or is accepted by, your preferred healthcare providers (primary doctor, specialists, etc.)
Enrolling in a Medicare Advantage Plan
You can join, switch, or drop a Medicare Advantage plan during:
- Annual Enrollment Period (AEP): October 15 to December 7 every year; change, switch, or leave plans.
- Initial Coverage Election Period (ICEP): Seven-month window to sign up for a Medicare Advantage plan; starts three months before your 65th birthday month and ends three months after.
- Medicare Advantage Open Enrollment (OEP): January 1 to March 31 every year; switch Advantage plans or return to Original Medicare (but you can’t join a new Advantage plan during this period).
- Special Enrollment Periods (SEPs): Certain life events (moving, losing coverage, etc.) may qualify you to change enrollment.
Comparing Medicare Advantage and Medigap
| Feature | Medicare Advantage (Part C) | Medigap (Supplement)* |
|---|---|---|
| Replaces Original Medicare | Yes | No – works together with it |
| Includes Part D | Often yes (but not always) | No – purchased separately |
| Provider Flexibility | Mostly limited to plan networks | Any provider that accepts Medicare |
| Prior Authorization | Usually required for specialist services | Usually not required |
| Added Benefits | May include | Rarely included |
| Out-of-Pocket Max | Yes | No |
* Must be purchased with Original Medicare (Parts A and B)
Medicare Advantage Frequently Asked Questions
Can I switch from Original Medicare (with a Medigap plan) to Medicare Advantage (or vice versa)?
In some cases yes, but timing matters. Moving from Medigap (with Original Medicare) to an Advantage plan is usually easier than switching the other way (due to medical review, also called underwriting). For timing, see the enrollment section above.Are all Medicare Advantage plans the same?
No. Plans vary by state, county, and provider network. That’s why local guidance from professional advisors is key.Do Advantage plans include drug coverage?
Most do, but not all. You’ll want to verify if the plan includes Part D coverage, and if it doesn’t you may need to enroll (and pay) separately in a Medicare Part D plan. Some beneficiaries may choose an Advantage plan without Part D if they get prescription drug coverage from another entity (such as the VA for veterans).
Medicare Part C
What are Medicare Advantage Plans?
Medicare Advantage plans, also known as Medicare Part C, are another way Medicare beneficiaries can receive benefits through private insurance companies.
A Medicare Advantage plan combines the benefits of Original Medicare, Part A (hospital) and Part B (medical), into a single plan. Medicare Advantage plans often include additional benefits not covered by Original Medicare. A Medicare Advantage plan can provide lower out-of-pocket costs and flexibility in choosing healthcare providers and services.
When you enroll in a Medicare Advantage plan, you still have Medicare coverage. However, with a Medicare Advantage plan, your healthcare services are managed through a private insurance plan, which usually includes a broker or agent (like us!)
Types of Medicare Advantage Plans
Health Maintenance Organization (HMO): An HMO plan requires you to partner with and use doctors and hospitals within the plan's network, except in emergencies.
Medicare Medical Savings Account (MSA): An MSA plan is similar to a Health Savings Account (HSA). Unlike other Medicare Advantage plans, an MSA doesn’t usually have a network of doctors, providers, hospitals, etc.
Preferred Provider Organization (PPO): A PPO plan allows you to partner with and use doctors and hospitals outside the network, but often, this flexibility comes at a higher cost.
Private Fee-for-Service (PFFS): A PFFS plan breaks down coverage and cost by determining how much the plan will pay doctors, other healthcare providers, and hospitals and how much you must pay for care.
Special Needs Plan (SNP): An SNP plan is available to people who have specific diseases or conditions, are eligible for Medicare and Medicaid, or live in certain facilities (like a nursing home).
Benefits of Medicare Advantage Plans
Comprehensive Coverage: Medicare Advantage plans allow you to consolidate coverage into a single plan. These plans typically include Medicare Part A (hospital) and Part B (medical) coverage, and many also offer Part D prescription drug coverage. Additionally, a Medicare Advantage plan could cover other health-related needs.
Cost-Effective Options: Medicare Advantage plans often have lower out-of-pocket costs than Original Medicare. This can include lower deductibles, copayments, and coinsurance for covered services. Some plans also have annual out-of-pocket maximums, providing financial protection against high healthcare expenses.
Managed Care Coordination: Many Medicare Advantage plans, such as HMOs or PPOs, operate under managed care models and can provide coordinated care options for beneficiaries. These plans may require you to choose a primary care physician and obtain referrals to see specialists.
Flexibility in Provider Choice: While some Medicare Advantage plans require you to use network providers, others offer flexibility to see out-of-network providers for a higher cost. This flexibility can benefit those who prefer continuity of care with their current healthcare providers.
Medicare Star Ratings: Medicare uses a five-star rating system to evaluate the quality of Medicare Advantage plans. Plans are rated on customer service, member satisfaction, and healthcare outcomes.
What to Consider When Choosing a Medicare Advantage Plan
When selecting a Medicare Advantage plan, it's essential to consider your individual healthcare needs, including additional benefits/coverage, prescription drug coverage, provider networks, and out-of-pocket expenses. Here are some factors to evaluate:
Costs: Compare the monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket-maximums for each Medicare Advantage plan against your current coverage.
Coverage Needs: Review the plan's benefits to ensure they align with your healthcare needs, including coverage for prescription drugs, dental, vision, and other services.
Plan Ratings: Use plan ratings to gauge the quality and performance of the plan.
Prescription Drug Coverage: Ensure your prescription drugs are included in the plan’s formulary (list of covered medications) and accessible at your preferred pharmacies.
Provider Network: Determine if the plan’s network includes or is accepted by your preferred healthcare providers (primary doctor, specialists, etc.)
When to Enroll in Medicare Advantage Plans
You can enroll in, switch, or drop a Medicare Advantage plan during one of the two main enrollment seasons:
Annual Enrollment Period (AEP): Every year from October 15th to December 7th, you can add or make changes to your Medicare Advantage plan.
Initial Enrollment Period (IEP): This is the seven-month window around your 65th birthday when you first become eligible for Medicare. It starts three months before your 65th birthday, includes your birthday month, and extends three months after.
Open Enrollment Period for Medicare Advantage Plans (OEP): If you're enrolled in a Medicare Advantage plan, you can switch to a different plan or return to Original Medicare from January 1st to March 31st each year.
Special Enrollment Periods (SEPs): Certain life events may qualify you for a Special Enrollment Period.
Understanding the Difference Between Medicare Supplement & Medicare Advantage Plans
It’s important to know the differences between Medicare Advantage plans (Part C) and Medicare Supplement/Medigap plans:
Medicare Supplement plans work with Original Medicare, while Medicare Advantage plans are an alternative to it.
Medigap plans work alongside Original Medicare, allowing you to see any Medicare-approved provider and offering more predictable costs.
Medicare Advantage plans often require prior authorization.