The Medigap Market
Medicare Part C: Medicare Advantage
What are Medicare Advantage Plans (Part C)?
A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. You’ll get your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from the Medicare Advantage Plan, not Original Medicare.
There are different types of Medicare Advantage Plans:
Health Maintenance Organization (HMO) Plans
In most HMOs, you can only go to doctors, other health care providers, or hospitals in the plan’s network except in an emergency. You may also need to get a referral from your primary care doctor.
Preferred Provider Organization (PPO) Plans
In a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You usually pay more if you use doctors, hospitals, and providers outside of the network.
Private Fee-for-Service (PFFS) Plans
PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they agree to treat you. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.
Special Needs Plans (SNP)
SNPs provide focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.
HMO Point-of-Service (HMOPOS) Plans
These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.
What else should I know about Medicare Advantage Plans?
You have Medicare rights and protections, including the right to appeal.
You can check with the plan before you get a service to find out if it’s covered and what
your costs may be. You must follow plan rules. It’s important to check with the plan for information about your rights and responsibilities.
If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong
to the plan, your services may not be covered, or your costs could be higher. In most
cases, this applies to Medicare Advantage HMOs and PPOs. If you join a clinical research study, some costs may be covered by Medicare and some by your plan.
Medicare Advantage Plans can’t charge more than Original Medicare for certain
services, like chemotherapy, dialysis, and skilled nursing facility care.
Medicare Advantage Plans have a yearly cap on how much you pay for Part A and Part B services during the year. This yearly maximum outof-pocket amount can be different between Medicare Advantage Plans and can change each year. You should consider this when you choose a plan.
Author: Jesse Bannister
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