Everything you need to know about Medicare Advantage (Part C)
HealthSpring has created this easy-to-follow guide to help you understand Medicare Advantage (Part C)—a powerful option that brings hospital, doctor, and often prescription drug coverage together in one plan.
What is Medicare Advantage (Part C)?
Medicare Advantage, also known as Part C, is an all-in-one alternative to Original Medicare (Parts A and B). These plans are offered by private insurance companies approved by Medicare, and they provide the same hospital and medical coverage as Original Medicare. Most Part C plans also include prescription drug coverage (Part D) and extras like dental, vision and hearing care.
It’s everything you get with Original Medicare—plus more—in one convenient plan.
What Medicare Advantage covers
Every Medicare Advantage plan must cover what Original Medicare does. Many plans go further, offering extra benefits on top of standard coverage that matter to your daily life:
- Hospital stays and emergency care (Part A).
- Doctor visits and outpatient care (Part B).
- Prescription drugs (Part D, if included).
- Vision, hearing, and dental services (varies by plan).
- Wellness programs and fitness memberships (varies by plan).
- Transportation to appointments or over-the-counter allowances (varies by plan).
Medicare Advantage plans (Part C) provide all of your Part A (hospital) and Part B (medical) coverage and must cover all medically necessary services. Many plans also offer Prescription drug coverage and additional programs not covered by Original Medicare. To enroll in a Medicare Advantage Plan, you must be eligible for and enrolled in Original Medicare Parts A and B and live within the plan's service area. You must continue to pay your Part B premium.
Who's eligible for Medicare Advantage?
You can join a Medicare Advantage plan if:
- You have Medicare Parts A and B.
- You live in the plan’s service area.
When can I enroll?
If you qualify, you can enroll during certain times of the year, including:
- Initial Enrollment Period (when you first become eligible for Medicare).
- Annual Enrollment Period (October 15 – December 7).
- Special Enrollment Periods (based on certain life events like moving or losing coverage).
Why choose Medicare Advantage?
It all comes down to what works best for you. Here are some reasons people choose Medicare Advantage:
- Simplicity: One plan, one card, one place to go for questions.
- Extra Benefits: Plans often cover services like dental, vision and hearing not covered by Original Medicare.
- Predictable Costs: Many plans have low or $0 premiums and set out-of-pocket limits.
- Coordination of Care: Many plans help manage care between providers.
Things to consider
Before enrolling, ask yourself:
- Are your doctors and specialists in the plan's network?
- Do you need prescription drug coverage?
- Are the extra benefits important to you?
- What are the monthly premiums and annual out-of-pocket costs?
It’s worth comparing your options to find the right fit for your health and your budget.
Do Medicare Advantage plans replace Medicare?
Medicare Advantage plans do not replace Medicare and are not Medicare Supplement policies, either. Part C plans provide an alternative to Original Medicare (Part A [hospital] and Part B [medical]) and can offer additional coverage, including prescription drug coverage and extra programs and services.
What are the pros and cons of a Part C Medicare Advantage plan?
Pros of Medicare Advantage plans
With Medicare Advantage plans, you can get personalized, coordinated medical care at a lower cost, depending on your plan. There are many advantages of enrolling in a Medicare Advantage plan. You can get:
- All of your coverage bundled together in 1 convenient plan.
- Costs that may be lower than Original Medicare.
- Extra benefits such as coverage for vision, hearing, dental, wellness programs, and discounts on health-related items.
- Prescription drug coverage (if it’s included as part of the plan).
- All the rights and protections offered through the Medicare program.
- Help paying for premiums (subsidies), if you qualify.
- All the benefits of Medicare Part A and Part B plans, without buying supplemental insurance.
Cons of Medicare Advantage plans
The following are some disadvantages of Medicare Advantage plans:
- If you select an HMO Medicare Advantage plan, you may have a smaller selection of providers to choose from. If you see an out-of-network provider, it can cost you more. However, other plan options will offer a wider provider network.
- With certain plans, you may see additional costs for things like drug deductibles and specialist visit copays.
- If you travel a lot, your plan may not cover standard services outside your service area. Emergency and urgent care services are covered outside your service area.
What types of Medicare Advantage plans are available?
There are various kinds of Medicare Advantage plans, such as HMO, PPO, and Private Fee-for-Service plans. HMOs and PPOs each have certain characteristics, whether they are part of a Medicare plan or part of a regular health plan.
For example, an HMO plan typically comes with lower costs but requires you to see providers within a network and get referrals before you see a specialist. A PPO plan typically costs more but offers more flexible options for seeing providers and may not require any referrals to see specialists.
Another kind of Medicare Advantage plan called Special Needs Plans helps customers with specific diseases, certain health care needs, or who also have Medicaid.
What does a Medicare Advantage plan cost?
Depending on your Medicare Advantage plan, the costs you pay out-of-pocket can vary:
- You may pay a deductible, a certain amount you must meet before your plan begins to pay.
- There may be copays for doctor visits—this is a flat fee usually due at the time of the visit.
- You may have to pay a share for lab services and medical equipment.
- You will pay a monthly plan premium if there is one.
- You will continue to pay the Original Medicare Part B monthly premium, as well.
- You may have additional coinsurance or copays if you see providers outside your plan network.
To help control your costs, make sure you understand the terms of your plan and the out-of-pocket costs you may be required to pay.
How do I choose a Medicare Advantage plan?
It’s important to compare the benefits between your current coverage and the different types of Medicare Advantage plans (Part C). Be sure that you understand the additional benefits and any benefits (or freedoms) that you may lose.
You may want to consider:
- If you can change your current doctors.
- If your medications are covered under the plan’s drug list formulary (if prescription drug coverage is provided).
- The monthly premium
- The cost of coverage. This could include annual deductible, copays, and coinsurance.
- What additional services are offered (i.e. preventive care, vision, dental, health club membership).
- Any treatments you need that aren’t covered by the plan.
How do I enroll in a Medicare Advantage plan?
If you want to enroll in a Medicare Advantage plan, you must:
- Be eligible for Medicare
- Be enrolled in both Medicare Part A and Medicare Part B (you can check this by referring to your red, white, and blue Medicare card)
- Live within the plan’s service area (which is based on the county you live in–not your state of residence)
- Not have end-stage renal disease (ESRD)
Want more information about enrollment? Visit Medicare Part C Eligibility and Enrollment Information
Special Enrollment Periods
If you need to change your MA plan outside of the standard enrollment periods described above, you may be eligible for a Special Enrollment Period (SEP) if you meet certain criteria, such as:
- Moving outside your plan's coverage area
- Being released from prison
- Experiencing a major natural disaster that impacts your area
- Losing Medicaid coverage due to a change in eligibility
- And more
To confirm if you're eligible for an SEP, contact us.