Home / Medicare Advantage
Medicare Advantage
Part C is Medicare delivered by a private company. It suits a lot of people very well, and a few people very badly. Here's how to tell which you are.
Part C
What Medicare Advantage is
An Advantage plan is Medicare coverage delivered by a private insurance company instead of directly by the government. The company is paid to manage your care, and in exchange it can bundle in extras.
- You keep paying Part BAn Advantage plan replaces how you receive benefits. It doesn't replace your Part B premium.
- It must cover what A and B coverBy law, at minimum. Most plans add prescription drugs, and many add dental, vision, hearing, or fitness benefits.
- There's a yearly ceilingEvery Advantage plan has a maximum out-of-pocket limit. Original Medicare on its own does not. This is the plan's biggest structural advantage.
- It runs on networksYou generally use the plan's doctors and hospitals, and some care needs the plan's approval before it's covered.
Plan types
The four letters you'll see
HMO
Lowest cost, tightest network. You pick a primary doctor, referrals are usually required, and out-of-network care generally isn't covered except emergencies.
HMO-POS
An HMO with a point-of-service option, letting you go outside the network for certain services at a higher cost.
PPO
More freedom. You can see out-of-network providers, though you pay more. Usually no referrals needed. Premiums tend to run higher.
PFFS
Private fee-for-service. The plan sets the terms and any provider who accepts them can treat you. Less common now, and you must confirm each provider accepts the plan.
Special Needs Plans
Plans built for a specific situation
If one of these fits you, it usually beats a general plan — and many people who qualify never find out.
C-SNP
For people with a qualifying chronic condition such as diabetes, heart failure, or COPD. Benefits and drug lists are shaped around that condition.
D-SNP
For people who have both Medicare and Medicaid. These often carry very low out-of-pocket costs and added benefits.
I-SNP
For people living in a nursing home or needing an institutional level of care.
Money
How the costs actually work
A $0 premium is not the same as $0 cost. You trade a monthly bill for payments at the point of care.
- PremiumOften $0 beyond your Part B premium. That's real, and it's why these plans are popular.
- CopaysYou pay as you go — per office visit, per test, per hospital day — until you reach the plan's yearly maximum.
- Maximum out-of-pocketThe ceiling on what you can spend in a year for in-network care. Look at this number before you look at the premium.
- Prior authorizationSome procedures need the plan's approval first. Ask how often the plan requires it for the care you actually use.
- NetworksCheck that your doctors are in-network every single year. Networks change in January.
Every September
The letter most people throw away
Your plan mails an Annual Notice of Change each fall. It lists every change to your premium, copays, drug list, and network for the coming year. Read it, or send it to us and we'll read it for you. This is how people discover in March that their doctor left the network in January.
- Late SeptemberThe notice arrives. Set it aside rather than binning it.
- October 15Annual enrollment opens. You can change plans for the coming year.
- December 7Annual enrollment closes. Whatever you have on this date is what you have in January.
Switching
When you can change your mind
- October 15 – December 7Annual enrollment. Switch Advantage plans, switch drug plans, or move back to Original Medicare.
- January 1 – March 31Advantage open enrollment. If you're on an Advantage plan you get one switch — to a different Advantage plan or back to Original Medicare.
- Any timeA special enrollment period may open if you move, lose other coverage, enter a nursing home, or qualify for Medicaid or Extra Help.
One warning worth repeating: moving back to Original Medicare is always allowed, but buying a supplement afterward may require answering health questions unless you have a guaranteed issue right. Going in is easy. Coming back out can be harder.
Now let's apply this to you.
Your doctors, your prescriptions, your zip code. Twenty minutes on the phone and you'll know where you stand.