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Medicare Part C: Medicare Advantage


Medicare Advantage Combines Part A and Part B benefits into one plan

Medicare Advantage plans are offered by private insurance companies approved by Medicare. Coverage and costs beyond the standards set by Medicare may vary from plan to plan.

Most include prescription drug coverage and offer additional benefits as well, often with no additional premium.


Plan types and service areas

Many Medicare Advantage plans are coordinated care plans. Plans contract with a network of doctors and hospitals to provide care to plan members. Plans may require members to choose a primary care doctor from the network to manage their care.


Medicare Advantage plans operate within defined geographic areas called service areas. You must live in a plan’s service area to become a plan member.


Coordinated care plans


Health Maintenance Organization plans (HMO)

  • Require you to seek care from providers in your network

  • Do not cover any of the cost for care you receive outside the network, except for emergency care, urgent care, and renal dialysis

  • May require you to choose a primary care provider, who may then manage any care you receive from specialists

  • May require you to get a referral from your primary care provider to see a specialist


Point of Service plans (POS)

  • A type of HMO plan that allows you to see doctors and hospitals outside the plan network for some covered services, usually for a higher copayment or coinsurance

  • May, or may not require you to get a referral for specialty services


Preferred Provider Organization plans (PPO)

  • Generally, offer more freedom to choose doctors and other providers

  • Don’t require a referral to see a specialist

  • Allow you to see providers outside the network, though you’ll usually pay more than you would with a network provider


Special Needs Plans (SNP)

  • Are designed for people with specific health care needs, including nursing home residents, those with chronic conditions and people who are eligible for both Medicare and Medicaid

  • May provide care managers or nurse practitioners to help members get the care they need

  • Usually, have plan-specific eligibility requirements


Other plan types


Private Fee-For-Service plans (PFFS)

  • Typically allow members to see any provider in the United States who accepts Medicare and the plan’s payment terms and conditions

  • Vary in their coverage and costs

  • Don’t require a referral to see a specialist


Medical Savings Account Plans (MSA)

  • Combine a high-deductible health plan with a special savings account

  • Funds received from Medicare are deposited into the savings account and may be withdrawn tax-free to pay qualified health care expenses

  • Do not include prescription drug coverage


What you pay for Part C



  • Medicare Advantage plans (Part C) may charge premiums, though some do not.

  • Plan premiums vary widely and can change from year to year.

  • You continue to pay your Part B premium and your Part A premium, if you have one, to Medicare.



Some Medicare Advantage plans charge a deductible and others don’t. Also, deductibles may be applied to drug benefits and not to medical benefits when a plan covers both. Deductible amounts may vary widely.



Many Medicare Advantage plans charge copays. You may pay a $15 copay for a doctor visit or a $10 copay for a prescription, for example. Copay amounts vary from plan to plan.



Copays are more common, but Medicare Advantage plans may set coinsurance terms for some services.


Out-of-pocket maximum

Medicare Advantage plans are required to set an out-of-pocket maximum. An out-of-pocket maximum is the total amount you might pay for covered health care services during the plan period — usually a calendar year.

  • Your plan pays all your covered costs for the rest of the plan period if you reach the out-of-pocket maximum.

  • Premium payments, drug costs and the cost of extra services a plan may cover, such as vision or dental care, do not count toward the out-of-pocket maximum.

  • Medicare places a limit on how high a plan can set its maximum. Plan maximums may be lower than the limit. The limit in 2019 is $6,700.

  • There is no out-of-pocket maximum with Original Medicare.


Compare plan prices

Medicare Advantage plan benefits and costs can vary widely, so be sure to shop around for a plan that works for you.

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