If you’re currently enrolled in Original Medicare, Part A and Part B, you may be wondering about other ways you can expand on your Medicare coverage. Medicare Advantage (Medicare Part C) is one of the ways you can do that. You can think of it as you another way to get your Original Medicare benefits, except instead of getting your coverage through the government-run program, you’ll get your benefits administered through your Medicare Advantage plan instead.
Medicare Advantage plans are offered through Medicare-approved private insurance companies. Each plan is required to offer at least the same level of coverage as Original Medicare, with the exception of hospice care, which is still covered under Part A of Original Medicare. As mentioned, one major benefit of Medicare Part C is that plans can provide a range of benefits not included in Part A and Part B, such as routine vision and dental services, prescription drugs, or health wellness programs.
You’re eligible for Medicare Part C if:
Benefits, costs, and plan availability may vary by insurance company and location. In addition, there may be a variety of different types of Medicare Advantage plans offered in your service area. Some of these plan types can include:
Understanding all of your options in Medicare Advantage will help you be better informed as you consider the type of coverage that may work best for your needs and preferences.
A Medicare Advantage Preferred Provider Organization (PPO) plan gives you the flexibility to see any doctor, provider, or hospital you want. However, you’ll usually pay less if you use providers in the plan’s preferred network. If you use non-network providers, your cost sharing (for example, copayments and coinsurance costs) is generally higher.
If you’re in a Preferred Provider Organization plan, you won’t have a primary care physician or need referrals to see specialists or other doctors.
A Medicare Advantage Health Maintenance Organization (HMO) plan requires you to use providers in the plan network to get covered. You’re usually not covered if you go out of the plan’s network, although there are often exceptions for medical emergencies, dialysis treatment, and urgent care.
You’ll have a primary care doctor and need referrals to see specialists. Your Medicare Advantage costs are generally lower in a Health Maintenance Organization plan than in a Preferred Provider Organization plan.
Some Health Maintenance Organization plans have a Point-of-Service (POS) option, which lets you use out-of-network providers for some health services. These plans are more of a hybrid between a Health Maintenance Organization plan and a Preferred Provider Organization plan. You’ll usually still have a primary care doctor and get most of your health services through the plan’s network providers. However, you’ll have the option in some cases to go out of this network, usually for a higher cost.
A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan that lets you use any provider that will accept the plan’s payment terms. With a PFFS plan, your doctor or provider must agree, on a case-by-case basis, to contract with the plan and treat you. Each Private Fee-for-Service plan decides how much to compensate providers to treat its members, and doctors are free to accept those terms and conditions or refuse to treat the patient. You should always verify that the provider accepts the plan’s payment terms before getting medical services, or your PFFS plan may not cover the costs. In medical emergencies, however, the plan will cover you even if the provider doesn’t accept the plan.
In some cases, PFFS plans may have provider networks of doctors and hospitals that have contracted with the plan to always provide you medical care, even if you haven’t seen them before. If your PFFS plan has a provider network, your cost sharing will be higher if you use out-of-network doctors.
You won’t have a primary care doctor or need referrals for this type of plan. You’re only responsible for cost-sharing requirements set by the plan.
Private Fee-for-Service plans may come include prescription drug coverage, but not always. If your plan doesn’t include drug benefits, you’re allowed to enroll in a stand-alone Medicare Prescription Drug Plan. Please note that this is one of the rare instances when you’re allowed to be in both a Medicare Advantage plan and a Medicare Prescription Drug Plan. (In most cases, if you’re in a Medicare Advantage plan and want prescription drug coverage, you must get it through a Medicare Advantage Prescription Drug plan.)
A Special Needs Plans (SNP) is a type of Medicare Advantage plan that limits membership to people who fit specific eligibility criteria. There are three types of Special Needs Plans, each targeting people with certain characteristics:
You’ll usually have a primary care physician (or a care coordinator who helps you manage your health) and need referrals to see specialists. You may not need a referral for certain preventive services, such as screening mammograms. Unlike other types of Medicare Advantage plans that may or may not include prescription drug coverage, all Special Needs Plans include prescription drug benefits.
Special Needs Plans usually require that members use in-network providers to be covered, unless it’s a medical emergency. Each Special Needs Plan usually has providers, formularies, and benefits that are tailored to the specific member needs for that plan. For example, a Dual Eligible Special Needs Plan might have special social services to help you manage your Medicare and Medicaid benefits.
If you’re eligible for a Special Needs Plan because you have a chronic condition, live in an institution, or are a dual eligible, you can enroll at any time with a Special Election Period.
A Medicare Medical Savings Account (MSA) plan is a high-deductible Medicare Advantage plan that includes a medical savings account; these plans are similar to Health Savings Account plans that may be available through an employer. Every year, the Medical Savings Account plan deposits money into a savings account that you can use to pay for medical costs until you reach the plan’s high deductible. Money that you withdraw from your medical savings account isn’t taxed as long it’s used to pay for qualified health costs. Any money that is left in the account at the end of the year rolls over to the next year and is added to the amount your plan deposits the following year.
If you use up the money in this savings account, you’ll pay for all health costs until you reach the plan’s high deductible, which varies from plan to plan. After your total spending on covered medical expenses reaches the deductible, the plan pays for all Medicare-covered benefits.
These plans give you provider flexibility and don’t usually require you to use in-network doctors. In addition, Medical Savings Account plans don’t include prescription drug coverage. If you need prescription drug benefits, you can get this coverage through a Medicare Prescription Drug Plan. This is another one of the rare times when you’re allowed to be in both a Medicare Advantage plan and a Medicare Prescription Drug Plan.
Hopefully, you now have a better idea of the different types of Medicare Advantage plans types and how they work. If you have questions about the specific plan options that may be available in your service area, an eHealth licensed insurance agent would be happy to discuss your coverage needs with you over the phone; just call the number on this page to get started. Or, if you prefer to browse plans now, enter your zip code into the plan finder tool on this page to view plan options in your location.
To learn about Medicare plans you may be eligible for, you can: