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What is Medicare Advantage? A Guide to Medicare Part C

Medicare Advantage, also known as Medicare Part C, consists of Medicare plans provided by private insurance companies approved by the Centers for Medicare & Medicaid Services (CMS). By law, these plans must offer benefits that are equal to or better than Original Medicare (Medicare Part A and Part B). Many Medicare Advantage plans also include prescription drug coverage (Medicare Part D), allowing enrollees to conveniently access a range of healthcare services through a single, comprehensive plan.

Additional Benefits Offered by Medicare Advantage

Depending on your location, some Medicare Advantage plans may offer extra benefits beyond standard Medicare coverage, including:

Vision care
Routine dental and/or hearing services
Allowances for eligible members to assist with costs related to:

Note: Availability of these benefits varies by plan and service area. Not all areas will have a plan that includes every benefit.

Cost-Saving Features

Many Medicare Advantage plans offer low monthly premiums and can help you save on:

Copayments
Coinsurance
Deductibles

Special Supplemental Benefits for the Chronically Ill (SSBCI)

Certain plans may provide Special Supplemental Benefits for members with specific chronic conditions. These benefits are available to individuals at high risk for hospitalization or who require intensive care coordination. Qualifying conditions may include (but are not limited to):

Diabetes mellitus
Cardiovascular disorders
Chronic lung disease
Chronic heart failure
Chronic and disabling mental health conditions

Meeting the criteria for a qualifying condition does not guarantee eligibility for these additional benefits. Further requirements may apply. For complete details, refer to your plan’s Evidence of Coverage.

Important Considerations

Medicare Advantage offers a comprehensive healthcare solution covering doctor visits, outpatient services, hospital care, and more. While these plans provide extensive coverage, services deemed medically unnecessary may not be covered. If you’re unsure whether a service is included, it’s best to confirm with your provider beforehand.

For personalized guidance and to explore your options, speak with a licensed insurance agent who can help you understand plan details and eligibility.

Understanding Medicare Advantage Networks

Medicare Advantage Plans generally operate through specific networks to manage your healthcare services. The most common networks include HMO, PPO, PFFS, HMOPOS, and MSA. Here’s a breakdown of how each network works:

1. Health Maintenance Organization (HMO)

HMO plans require you to use a specific network of doctors and healthcare providers. In most cases, you’ll need a referral from your primary care physician (PCP) to see a specialist. These plans often include additional benefits, such as coverage for deductibles and more.

2. Preferred Provider Organization (PPO)

With a PPO plan, you can save money by using doctors and facilities within the plan’s network. You still have the flexibility to see out-of-network providers, but you may pay higher out-of-pocket costs.

3. Private Fee-For-Service (PFFS)

PFFS plans work similarly to Original Medicare, but the plan determines how much it will pay providers and how much you will pay out-of-pocket. Not all doctors or facilities accept PFFS plans, so always check if your provider participates.

4. HMO Point-of-Service (HMOPOS)

An HMOPOS plan functions like a traditional HMO but allows you to receive some services from out-of-network providers—usually at a higher copayment or coinsurance rate.

Key Advantages of Medicare Advantage

Includes coverage for Medicare Parts A and B
Access to additional benefits such as vision, dental, and hearing coverage*
May have lower out-of-pocket costs than Original Medicare
Prescription drug coverage
Access to health and wellness programs
All-in-one convenient plan

What do Medicare Advantage Plans Cover?

Medicare Advantage plans cover a wide range of services for new and existing enrollees seeking convenient, well-rounded coverage. These include benefits not offered by Original Medicare, such as vision, hearing, and dental services as well as non-emergency care.

Medicare Advantage vs. Medicare Supplement:

AREA OF COMPARISON	MEDICARE ADVANTAGE	MEDICARE SUPPLEMENT
Coverage	Covers all services under Medicare Parts A & B, and may offer additional benefits.	Covers specific out-of-pocket costs not covered by Medicare, such as deductibles, coinsurance and copays
Cost	Offers lower, or sometimes no monthly premiums.	Features consistent monthly premiums although these are often more expensive.
Provider Network	Enrollees are limited to a provider network for coverage, with no coverage outside the U.S.	Enrollees may see any provider who accepts Medicare.
Prescription Drug Coverage	Most Medicare Advantage plans include prescription drug coverage.	Does not cover Prescription Drug Plans; must enroll in Medicare Part D.

Is Medicare Advantage Right for Me?

Deciding if Medicare Advantage is the right choice depends on your healthcare needs, lifestyle, and budget. It is essential to evaluate the specific services you require and compare them with the coverage options available.If you are unsure which plan best fits your needs, a licensed Assurance Life Group insurance agent can guide you through the process and help you make an informed decision with confidence.

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Frequently Asked Questions About Medicare Advantage Plans

Am I eligible for a Medicare Advantage Plan?

You are likely eligible for a Medicare Advantage Plan if you meet the following qualifications:

Are enrolled in Parts A and B at time of application
If you are age 65 or older
You’re a U.S. citizen or lawfully reside in the service area of the plan you wish to join
If you have End-State Renal Disease or ALS

Can I get Medicare Advantage if I have employer coverage?

If you have employer coverage, you may still be eligible to enroll in Medicare Advantage if you meet the qualifications for Medicare coverage. It’s important to review your employer coverage to ensure you’re making the right decision for your budget and coverage needs

What costs are associated with Medicare Advantage plans?

Medicare Advantage plans are offered by private insurance companies under contract with the Federal government, therefore, they vary in cost, coverage, copays, and deductibles. Some Medicare Advantage plans provide affordable or $0 premiums, with a variety of coverages and benefits not included in Original Medicare.

Note that even with a $0 premium Medicare Advantage plan, you’ll still pay a monthly premium for Part B, and a Part D premium if your Medicare Advantage plan does not include prescription drug coverage (MA-PD).

What should I do if I’m eligible for both Medicare and Medicaid?

If you’re eligible for both Medicare and Medicaid, you’ll receive “dual eligibility” status, which allows you to take advantage of the benefits offered by each program. These are called Dual-Special Needs Plans.

If this applies to you, Medicare will typically be your primary insurance and Medicaid will be your secondary insurance. Medicare covers most of your health care costs and Medicaid will cover the remaining costs that Medicare does not cover.

Can I switch from a Medicare Advantage plan to Medicare Supplement?

Yes, during enrollment periods. Switching from Medicare Advantage to Medicare Supplement (Medigap) coverage is possible if you meet the requirements. You’ll probably be required to answer certain underwriting questions. If you pass medical underwriting, you can enroll during enrollment periods during the year, including Fall Open Enrollment (Oct. 15 to Dec. 7) or Medicare Advantage Open Enrollment (Jan. 1 to March 31).

Why should I work with an agent for my Medicare Advantage needs?

Understanding Medicare Advantage coverage can be an overwhelming process, with a variety of carriers, networks, industry terms, and definitions to understand. Working with a licensed SmartMatch agent can streamline this process. Your SmartMatch agent helps you understand and prioritize your needs, then delivers a variety of options for you to compare and make the right coverage plan decisions.