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Medicare Part C (Medicare Advantage)

Medicare Advantage is a type of Medicare Plan offered by a private company that provides a person with all Medicare Part A and Part B benefits, and often additional benefits as well. Also called Part C, Medicare Advantage Plans can be:

  • HMOs (health maintenance organizations),
  • PPOs (preferred provider organizations),
  • Private Fee-for-Service Plans,
  • Medical Savings Account Plans (MSAs), and
  • Medicare Special Needs Plans

If a person is enrolled in a Medicare Advantage Plan, all Original Medicare services are covered through the plan and aren't paid for under Original Medicare. Most Medicare Advantage Plans also offer prescription drug coverage that must follow the same rules as Medicare Prescription Drug Plans (Part D).

Medicare Advantage Plans may also offer more benefits than Original Medicare, such as vision, hearing, dental, and/or health and wellness programs. These plans also may have lower out-of-pocket costs than Original Medicare. In some plans, like HMOs, you may only be able to see certain doctors or go to certain hospitals to get covered services. Medicare Advantage plans are available in many areas of the country.

All people pay a monthly premium for their Medicare Advantage Plan. This payment is in addition to the monthly premium paid for Part B.

How Medicare Advantage Plans Work

PPO and HMO Plans
Source: Information from the official government handbook published by the Centers for Medicare and Medicaid Services: Medicare & You 2010
Health Maintenance Organization (HMO) Plan Preferred Provider Organization (PPO) Plan
Can I get my health care from any doctor or hospital? No. You generally must get your care and services from doctors or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services usually for a higher cost. Yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.
Are prescription drugs covered? In most cases, yes. Ask the plan. If you want drug coverage, you must join in an HMO Plan that offers prescription drug coverage. In most cases, yes. Ask the plan. If you want drug coverage, you must join a PPO Plan that offers prescription drug coverage.
Do I need to choose a primary care doctor? In most cases, yes. No.
Do I have to get a referral to see a specialist? In most cases, yes. Yearly screening mammograms and in-network Pap tests and pelvic exams (at least every other year) don't require a referral. No.
What else do I need to know about this type of plan?
  • If your doctor leaves the plan, your plan will notify you. You can choose another doctor in the plan.
  • If you get health care outside the plan's network, you may have to pay the full cost.
  • It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.
  • There are two types of PPOs — Regional PPOs and Local PPOs.
  • Regional PPOs serve one of 26 regions set by Medicare.
  • Local PPOs serve the counties the PPO Plan chooses to include in its service area.
PFFS and MSA Plans
Source: Information from the official government handbook published by the Centers for Medicare and Medicaid Services: Medicare & You 2010
Private Fee-for-Service (PFFS) Plan Medical Savings Account (MSA) plan
Can I get my health care from any doctor or hospital? In some cases, yes. You can go to any Medicare-approved doctor or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will. If you join a PFFS Plan that has a network, you will usually pay more to see out-of-network providers. Yes. Some plans may have preferred doctors and hospitals you could go to for a lower cost.
Are prescription drugs covered? Sometimes. If your PFFS Plan doesn't offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage. No. You can join a Medicare Prescription Drug Plan to get drug coverage.
Do I need to choose a primary care doctor? No. No.
Do I have to get a referral to see a specialist? No. No.
What else do I need to know about this type of plan?
  • PFFS Plans aren't the same as Original Medicare or Medigap.
  • The plan decides how much you must pay for services.
  • Doctors, hospitals, and other providers may decide on a case-by-case basis not to treat you even if you've seen them before.
  • For each service you get, check to make sure your doctors, hospitals, and other providers will agree to treat you under the plan, and that they will accept the PFFS Plan's payment terms.
  • In an emergency, doctors, hospitals, and other providers must agree to treat you.
  • Medicare MSA Plans have two parts: a high deductible health plan and a bank account. Medicare gives the plan an amount each year for your health care, and the plan deposits a portion of this money into your account. The amount deposited is less than your deductible amount, so you will have to pay out-of-pocket before your coverage begins.
  • Money spent for Medicare-covered Part A and Part B services counts toward your plan's deductible. After you reach your out-of-pocket limit, your plan will cover your Medicare-covered services in full.
  • Any money left in your account at the end of the year remains in your account along with the deposit for next year.
Special Needs Plans
Source: Information from the official government handbook published by the Centers for Medicare and Medicaid Services: Medicare & You 2010
Can I get my health care from any doctor or hospital? You generally must get your care and services from doctors or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis). Plans typically have specialists for the diseases or conditions that affect their members.
Are prescription drugs covered? Yes. All SNPs must provide Medicare prescription drug coverage (Part D).
Do I need to choose a primary care doctor? Generally, yes, or you may need to have a care coordinator to help plan your care.
Do I have to get a referral to see a specialist? In most cases, yes. Yearly screening mammograms and an in-network Pap test and pelvic exam (at least every other year) don't require a referral.
What else do I need to know about this type of plan?
  • A plan must limit plan membership to people in one of the following groups 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have one or more specific chronic or disabling conditions (like diabetes, congestive heart failure, a mental health condition, or HIV/AIDS).
  • A plan may further limit membership within these groups.
  • Plans should coordinate the services and providers you need to help you stay healthy and follow your doctor's orders.
  • If you have Medicare and Medicaid, your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.
  • If you live in an institution, make sure that plan doctors or other health care providers serve people where you live.

Who Can Enroll in a Medicare Advantage Plan?

You can generally join a Medicare Advantage Plan if you meet these conditions:

  • You have Part A and Part B.
  • You live in the service area of the plan. Contact the plans you're interested in to find out about the service area.
  • You don't have End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant).

How Much do Medicare Advantage Plans Cost?

The out-of-pocket costs for a Medicare Advantage Plan vary widely, and depend on the following:

  • Whether the plan charges a monthly premium in addition to your Part B premium. Medicare Advantage Plans charge one combined premium for Part A and Part B health coverage, Medicare prescription drug coverage (Part D) (if offered), and extra coverage (if offered).
  • Whether the plan pays any of the monthly Part B premium.
  • Whether the plan has a yearly deductible or any additional deductibles.
  • How much you pay for each visit or service (copayments).
  • The type of health care services you need and how often you get them.
  • Whether you follow the plan's rules, like using network providers.
  • Whether you need extra coverage and what the plan charges for it.

A few Medicare Advantage plans may pay all or part of your Part B premium. (You still get all Part A and Part B-covered services). Your Medicare Advantage plan premium may also include all or part of the premium for Medicare prescription drug coverage (Part D).

How to Enroll in and Switch Medicare Advantage Plans

Once you choose a Medicare Advantage Plan, you may be able to join by completing a paper application, calling the plan, or enrolling online. Talk with the plan to find out how you can join. When you join a Medicare Advantage Plan, you will have to provide your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.

  • To switch to a new Medicare Advantage Plan, simply join the plan you choose during a period listed on When to Enroll section. You will be disenrolled automatically from your old plan when your new plan's coverage begins.
  • To switch to Original Medicare, contact your current plan or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Most of the information on this Resource Center was obtained from government agency websites and publications, including the Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (DHHS), National Institutes of Health (NIH) and Social Security Administration (SSA). All content is provided for informational purposes only and is subject to change without notice. Although we believe that the source of this information is reliable, we do not warrant or guarantee its accuracy, completeness or timeliness.

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