What is Medicare Advantage or Part C?

Medicare Advantage plans are Medicare-approved, but offered by private insurers. These Medicare plans combine Part A and Part B, and often Part D prescription drug benefits into one plan. These plans are managed care or HMO and PPO plans that use a network of doctors. Some Medicare Advantage plans also offer additional benefits such as vision, dental, hearing and/or health and wellness programs at no extra cost!

Note: Medicare Advantage (Part C) is NOT the same as Medigap (Medicare Supplement)! The plans work differently because Medicare Advantage plans pay instead of Medicare, not after Medicare pays their share. Learn more about how Medicare Supplement (Medigap) works here (link to medigap page).

Why choose Medicare Advantage?

Let’s look at Original Medicare (link to OM page) or Part A & B and the issues that arise with this coverage. With original medicare, you are able to go to any doctor who takes Medicare in the country. This sound nice, but how do you find a good doctor, specialist, hospital, and keep track of the care you have received? You will also have deductibles to meet and 20% coinsurance to be responsible for both part A and Part B.

This is where Medicare Advantage health plans make sense. Instead of Medicare paying the bill, now the private insurance company is the payer. Generally you will be a part of a local network and you will need to see the networks doctors and use network facilities. You may pay co-payments for health services and each plan sets its own cost sharing. The network you choose will do all the hard work of finding doctors and specialists for you and will allow all services received to be easily communicated between these doctors and facilities.

Medicare Advantage plans can change each year so Medicare itself states

Limitations, copayments and restrictions may apply, and each plan’s benefits, formulary, pharmacy network provider network, premium and copayments may change on January 1 of each year.”

So Medicare Advantage members need to be diligent about reviewing the plan materials sent to them each year in September to see what’s changing the following year.

What does Medicare Advantage (Part C) cover?

Medicare Part C is required to cover all of the same Part A and B services that you get from Original Medicare. However, because the private insurance plan is now paying, instead of paying Part A & B deductibles and 20% of your medical services, you will pay the plan’s premium and copayments.

Each Medicare Advantage plan may have different copayments so each plan has a summary of benefits. In this summary, it will list out various medical services that are covered and their payments.

For example: You might pay $0 monthly premium, $5 copay for primary care physician visit,  $10 copay for a specialist visit, $200 copay for an MRI – and so on.

The highest amount that you will pay in the network for any service is 20% and depending on the plan and service area, plan premiums and copayments can be a low as $0. Typically we see a 20% coinsurance requirement for things like durable medical equipment, chemotherapy, doctor administered drugs, and radiation. You and your agent will receive the summary of benefits carefully to see what you can expect to pay and if it fits your needs.

Advantage plans are also required to have an out-of-pocket maximum (M.O.O.P.) on your medical spending. This is your “safety net. ” If you have heavy health spending that results in a certain out-of-pocket limit, then the plan kicks in and pays the rest for the remainder of the calendar year. The Medicare stated M.O.O.P. is $6700 for each calendar year and can often be less than this depending on the plan. Drug expenses are calculated separately.

Many Medicare Part C plans often include a built-in Part D drug plan. This means you will have all of your medical and drug expenses covered by just 1 plan. Each plan uses a different “formulary”, or drug list, and has different price tiers for certain drugs. So checking all of your prescriptions with each plan is highly recommended. Be sure to sit down with your agent and check all your medications before making a choice.

Does Medicare Advantage sound like a good fit for you? Contact us today and an agent can sit down with you and go over any questions you may have and show you your options.