Medicare Advantage (Part C)
What is Medicare Advantage?
Medicare Advantage is also known as Part C or MA plans, which “bundles” Original Medicare Part A and Part B into one health insurance plan. Original Medicare is a health insurance program administered by the federal government, but Medicare Advantage plans are offered by health insurance companies approved by the federal government.
Medicare Advantage plans can also include Part D - prescription drug coverage.
Medicare Advantage plans can also include extra services not included in Part A and Part B, such as vision, hearing, dental, and wellness programs.
Who is eligible for Medicare Advantage?
Medicare Advantage (Part C) has the same eligibility requirements as Original Medicare Part A and Part B.
In general, you must be entitled to Part A and enrolled in Part B to enroll in Part C. People 65 or older are eligible for Part C. Younger people with certain disabilities can also be eligible for Part C.
If you are 65 or older, you are eligible for Part C if:
- You currently receive retirement benefits from Social Security or the Railroad Retirement Board.
- You are currently eligible for Social Security or the Railroad Retirement Board benefits but you haven’t applied for them yet.
If you are under 65, you are eligible for Part C if:
- You have received Social Security or the Railroad Retirement Board disability benefits for 24 months
- You have End-Stage Renal Disease (ESRD) and meet certain criteria
What does Medicare Advantage cover?
Medicare Advantage plans are required to cover the same benefits as Original Medicare Part A and B:
Part A (hospital insurance) helps cover:
- Inpatient hospital care
- Skilled nursing facility care
- Long-term care hospitals
- Nursing home care
- Home health services
Part B (medical insurance and doctor visits) helps cover:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Partial hospitalization
- Getting a second opinion before surgery
- Limited outpatient prescription drugs
Many Medicare Advantage plans may include additional coverage such as vision, hearing, dental, and wellness programs. Most Medicare Advantage plans also include Medicare Part D - prescription drug coverage.
Part D (prescription drug) plans each have a list of prescription drugs which are covered. This list is known as a formulary.
Is there a monthly premium cost for Medicare Advantage plans?
Usually. Some Medicare Advantage plans have a $0 premium while others have a monthly premium cost in addition to the Part B premium.
(The standard monthly premium amount for Part B in 2021 is $148.50, but this can be greater if you have a high income. Most people who receive Social Security benefits will pay a lower amount).
What are the out-of-pocket costs (deductible, coinsurance) for Medicare Advantage plans?
Different Medicare Advantage plans can have different out-of-pocket costs. These costs can vary depending on:
- Whether the plan charges a monthly premium.
- Whether the plan pays any of your monthly Medicare Part B (Medical Insurance) premium.
- Whether the plan has a yearly deductible or any additional deductibles.
- How much you pay for each visit or service (copayment or coinsurance). For example, the plan may charge a copayment, like $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare.
- The type of health care services you need and how often you get them.
- Whether you go to a doctor or supplier who accepts Medicare assignment (if you're in a PPO, PFFS, or MSA plan and you go out-of-network).
- Whether you follow the plan's rules, like using network providers.
- Whether you need extra benefits and if the plan charges for it.
- The plan's yearly limit on your out-of-pocket costs for all medical services.
- Whether you have Medicaid or get help from your state.
When can I enroll in Medicare Advantage plans?
There is a 7 month initial enrollment period for Part C - Medicare Advantage. You can enroll starting 3 months before the month you turn 65, during the month you turn 65, and 3 months after your birthday month. Other enrollment time periods apply if you are eligible due to disability or ESRD.
If you are not satisfied with your Medicare Advantage plan, you are allowed to change plans during the Annual Election Period (AEP), October 15th to December 7th or the Open Enrollment Period (OEP), January 1 to March 31st.
Is there a penalty for signing up late for Part C?
No, signing up for Medicare Part C - Medicare Advantage is voluntary and there is not a direct penalty for signing up late. However, there is a penalty for signing up late for Part A and B, and due to the fact Part C bundles Original Medicare Part A and B into one plan, you may face the penalties associated with Part A and B when you sign up for Part C.
What are the differences between Original Medicare Part A & B vs. Medicare Advantage
Original Medicare Part A & B is administered by the federal government, while Medicare Advantage plans are run by health insurance companies, which are approved by the federal government. The following table summarizes other differences between Original Medicare and Medicare Advantage.
|Original Medicare Part A & B||Medicare Advantage (Part C)|
|Doctor Network||Any doctor who accepts Medicare||May be required to go to a doctor within the plan's network.|
|Referral to see Specialist||No||Usually required for HMO plans. Not for PPO plans.|
|Routine Care||Anywhere in the country||May be required to stay in local area|
|Emergency Care||Anywhere in the country||Anywhere in the country|
|Prescription Drugs||Need separate Part D plan||Part D is usually included|
|Out-of-pocket spending limit||No limit||Limits on out-of-pocket costs|
|Extra coverage included - vision, dental, hearing||No||Usually|
|5-star quality ratings||No||Yes|
For more information on this topic, please visit www.medicare.gov