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Medicare Part C: Medicare Advantage

Medicare Advantage is Part C of Medicare and it is provided by private insurance companies that contract with Medicare. While Medicare Supplement Insurance (Medigap) is a supplement to Original Medicare, Medicare Advantage is an alternative way for people to get Medicare benefits. Medicare Advantage plans must provide at least what Original Medicare would provide in terms of benefits. Generally Part C: Medicare Advantage Plans may include additional benefits such as prescription drugs, routine dental and vision care, hearing and can even reduce the out-of-pocket costs associated with Original Medicare.

Medicare Advantage Plans will usually have a monthly premium in addition to your Part B premium. Medicare Advantage plans may have many bells and whistles and the trade-off for all these benefits could be the area of service a Medicare Advantage Plan covers. Original Medicare is accepted by any doctor that accepts Medicare assignment (nationwide) but Medicare Advantage is limited to a provider network. Medicare Advantage plans are usually HMOs or PPOs though there are PFFS and SNPs.

  1. Health Maintenance Organizations (HMO) are health insurance plans that require a primary care physician and they act as the hub that links you to other doctors within the provider network.
  2. Preferred Provider Organizations (PPO) are more flexible than HMOs and allow you to see doctors as you please but doctors within the provider network will be significantly cheaper.
  3. Private Fee-for-Service (PFFS) plans are provided by private insurance companies. PFFS plans are not the same as Original Medicare. The plan will determine how much it will pay and how much you must pay for care and services. Some PFFS will have a network providers.
  4. Special Needs Plans (SNPs) are provided by private insurance companies but SNPs limit memberships to those with specific diseases or characteristics so plans can be specifically tailored a more focused group of individuals.

When can I enroll in a Medicare Advantage plan?

Medicare Advantage has 3 times to sign up.

  1. Initial Election Period when you first become eligible for Medicare or when you turn 65. This is a 7-month period which includes the 3 months before the month you turn 65, the month you turn 65, and the 3 months following the month you turn 65.
  2. Medicare Annual Election Period which is from October 15- December 7 every year.
  3. Special Election Periods are when certain events cause you to lose coverage or gain additional benefits like moving or becoming eligible for Medicaid.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether they will cover an out-of-network service, they encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call their customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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