Medicare Advantage Plans

May 19th, 2017     Medicare

Medicare Part C plans are also referred to as Medicare Advantage plans. These plans are offered by private insurance companies and allow you to get all the coverage Original Medicare (Parts A and B) offers, plus additional benefits and services all in a single plan. Many Medicare Advantage plans include prescription drug coverage (Part D), often for no additional premium or for small premium amount. Some plans also include extra benefits such as:

  • Routine vision, hearing and dental care
  • Wellness programs

Different Types Of Medicare Advantage Plans:

Most Medicare Advantage plans are built on the idea of a network of doctors and hospitals working together to provide care. Each MA plan creates its own network of doctors and other health service providers. In most cases, you will pay most or all costs if you see a provider outside of the network.

  1. Health Maintenance Organization (HMO) Plans: HMO plans require you to seek care from providers in your network. Many require you to get a referral from your primary care physician to see a specialist.
  2. Point Of Service (POS) Plans: A type of HMO plan that allows you to see doctors and hospitals outside the network for some covered services, usually for a higher co‑pay or co‑insurance.
  3. Preferred Provider Organization (PPO) Plans: PPO plans typically don’t require a referral to see a specialist and allow you to see providers outside the network without having to pay the entire cost yourself.
  4. Special Needs (SNP) Plans: SNPs are designed for people with a range of special needs, including those with chronic diseases, nursing home residents, and people who are eligible for both Medicare and Medicaid.
  5. Private Fee-For-Service (PFFs) Plans: PFFS plans allow enrollees to see any providers in the U.S. who accept Medicare’s payment terms and conditions.
  6. Medical Savings Account (MSA) Plans: MSA plans combine Medicare Advantage plan coverage with a special savings account you can use to pay for covered expenses tax‑free.

Premiums and other Costs:

Medicare Advantage plans can reduce the costs and the hassle for patients who need to buy three policies (Part A, Part B and Drug Plan) for comparable coverage in traditional Medicare, and a supplemental policy that covers out-of-pocket costs. Read our guide to understand differences between Original Medicare and Medicare Advantage Plans.

Only private insurance companies that are approved by Medicare can provide Part C coverage. Insurance companies decide what services the plan will cover, so monthly premiums vary from plan to plan (and state to state) and they are only allowed to make changes to the premium rate once a year. Part C premiums are billed through the private insurance company. You will have to pay a monthly premium (in addition to your Part B premium, although many MA plans comes with $0 monthly premiums). Most Medicare Advantage plans use a combination of deductibles, co‑insurance and co‑payments to share the costs of your care with you. Deductibles, co-pays and co-insurance, plus all costs for ‘services that aren’t covered’ are called “out-of-pocket costs”.

  • Co-insurance: The costs that you and the health insurance plan pay are split on a percentage basis.
  • Co-payments: The fixed amount you pay at the time you receive a covered service.
  • Deductible: A set amount you pay out of pocket for covered services each year before your plan begins to pay.

Out-of-pocket: The maximum amount you pay during a policy period (usually a year). This amount does not include your premium or the cost of any services that are not covered by your plan. After you reach your out‑of‑pocket maximum, your plan pays 100% of the allowed amount of covered services for the rest of the policy period.

When can You Join or Switch to a Medicare Advantage Plan:

  • If you have Part A coverage and Part B coverage during the General Enrollment Period, you can also join a Medicare Advantage Plan.
  • Between Oct 15 – Dec 7, anyone with Medicare can join, switch, or drop a Medicare Advantage Plan. Your coverage will begin on Jan 1, as long as the plan gets your request by Dec 7.
  • Between Jan 1–Feb 14, if you’re in a Medicare Advantage Plan, you can leave that plan and switch to Original Medicare.
  • You may lose your prescription drug coverage if you move from a Medicare Advantage Plan that has drug coverage to a Medicare Advantage Plan that doesn’t.
  • In certain situations, you may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period. You can only use this Special Enrollment Period once during this time-frame.

Renewal: Your plan renews automatically each year as long as you pay the premium and the plan is still available in your service area.

How To Choose A Type Of Medical Advantage Plan:

  1. Convenience: Check the network of the MA Plan – Where are the doctors’ offices, which pharmacies can you use, whether your favorite doctor is part of the network, whether you’ll require a referral to visit a specialist etc.
  2. Costs: How much are your premiums, deductibles, and other costs? Is there a yearly limit on the out-of-pocket expenses?
  3. Costs: How well does the plan cover the services you need?
  4. Prescription Drugs: Do you need to join a Medicare drug plan? Are your drugs covered under the plan’s formulary?
  5. Travel: Will you have coverage in another state or outside the U.S.?

Important Points To Be Considered:

  • If you’re in a Medicare Advantage Plan, review the Evidence of Coverage (EOC) and Annual Notice of Change (ANOC) your plan sends you each year. If you don’t get these important documents before the start of Open Enrollment, contact your plan.
  • If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your services may not be covered, or your costs could be higher. In most cases, this applies to Medicare Advantage HMOs and PPOs.
  • Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.
  • Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for medical services. Once you reach this limit, you’ll pay nothing for covered services. This limit may be different between Medicare Advantage Plans and can change each year.
  • If your Medicare Advantage Plan includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you’ll be dis-enrolled from your Medicare Advantage Plan and returned to Original Medicare.
  • You can’t use (and can’t be sold) a Medicare Supplement Insurance (Medigap) policy while you’re in a Medicare Advantage Plan. You can’t use it to pay for any expenses (co-payments, deductibles, and premiums) you have under a Medicare Advantage Plan. If you already have a Medigap policy and join a Medicare Advantage Plan, you’ll probably want to drop your Medigap policy. If you drop your Medigap policy, you may not be able to get it back.


  • can show you the plans available in your area.
  • The Medicare Helpline can answer your Medicare questions. Call 1-800-MEDICARE (1-800-633-4227).


Medicare Program: Medicare is a federal government program which provides health insurance to people who are 65 or older. This program also covers certain younger people with disabilities (who receive Social Security Disability Insurance - SSDI), and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD.

Medicare Assignment: Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services. Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.

NPI Number: The National Provider Identifier (NPI) is a unique identification number for covered health care providers. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA (Health Insurance Portability and Accountability Act).

Our Data: Information on is built using data sources published by Centers for Medicare & Medicaid Services (CMS) under Freedom of Information Act (FOIA). The information disclosed on the NPI Registry are FOIA-disclosable and are required to be disclosed under the FOIA and the eFOIA amendments to the FOIA. There is no way to 'opt out' or 'suppress' the NPPES record data for health care providers with active NPIs.