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What do Medicare Advantage (Part C) plans cover?
Medicare Advantage plans (Part C) provide all of your Part A (hospital) and Part B (medical) coverage and must cover all medically necessary services. Many plans also offer prescription drug coverage and additional programs not covered by Original Medicare. To enroll in a Medicare Advantage Plan, you must already have Original Medicare Part A and B coverage.
Part C
Medicare Advantage Plan
Part A
Hospital
+
Part B
Medical
+
Part D
Prescription
- Combines Original Medicare, Part A and Part B, in 1 plan
- Often also includes Medicare Part D prescription drug coverage
- May come with additional programs and services not offered by Original Medicare
These plans are part of the government's Medicare program, but are offered and managed through private insurers, like Cigna. Medicare Advantage Plans may include plan extras not found in Original Medicare. You must be enrolled in Medicare Part A and Part B to join.
Do Medicare Advantage Plans replace Medicare?
Medicare Advantage plans do not replace Medicare and are not a Medicare Supplement plan, either. Part C plans provide an alternative to Original Medicare (Part A [hospital] and Part B [medical]) and can offer additional coverage, including prescription drug coverage and extra programs and services.
Confused by Medicare terms?
What are the pros and cons of a Medicare Advantage plan?
Pros of Medicare Advantage Plans
With Medicare Advantage plans, you can get personalized, coordinated medical care at a lower cost, depending on your plan. There are many advantages of enrolling in a Medicare Advantage plan. You can get:
- All of your coverage bundled together in 1 convenient plan.
- Costs that may be lower than Original Medicare.
- Extra benefits such as coverage for vision, hearing, dental, wellness programs, and discounts on health-related items.
- Prescription drug coverage (if it’s included as part of the plan).
- All the rights and protections offered through the Medicare program.
- Help paying for premiums (subsidies), if you qualify.
- All the benefits of Medicare Part A and Part B plans, without buying supplemental insurance.
Cons of Medicare Advantage Plans
The following are some disadvantages of Medicare Advantage plans:
- If you select an HMO Medicare Advantage plan, you may have a small selection of providers to choose from. If you see a provider out-of-network, it can cost you more. However, other plan options will offer a wider provider network.
- With certain plans, you may see additional costs for things like drug deductibles and specialist visit copays.
- If you travel a lot, your plan may not cover services outside your service area.
What types of Medicare Advantage plans are available?
There are various kinds of Medicare Advantage plans, such as HMO, PPO, and Private Fee-for-Service plans. HMOs and PPOs each have certain characteristics, whether they are part of a Medicare plan or part of a regular health plan.
For example, an HMO plan typically comes with lower costs but requires you to see providers within a network and get referrals before you see a specialist. A PPO plan typically costs more, but offers more flexible options for seeing providers and may not require any referrals to see specialists.
What does a Medicare Advantage plan cost?
Depending on your Medicare Advantage plan, the costs you pay out-of-pocket can vary:
- You may pay a deductible, a certain amount you must meet before your plan begins to pay.
- There may be copays for doctor visits—this is a flat fee usually due at the time of the visit.
- You may have to pay a share for lab services and medical equipment.
- You will pay a monthly plan premium if there is one.
- You will continue to pay the Original Medicare Part B monthly premium, as well.
- Additional coinsurance or copays if you see providers outside your plan network.
To help control your costs, make sure you understand the terms of your plan and the out-of-pocket costs you may be required to pay.
How do you choose a Medicare Advantage plan?
It’s important to compare the benefits between your current coverage and the different types of Medicare Advantage plans (Part C). Be sure that you understand the additional benefits and any benefits (or freedoms) that you may lose.
You may want to consider:
- If you can change your current doctors
- If your medications are covered under the plan’s formulary (if prescription drug coverage is provided)
- The monthly premium
- The cost of coverage. This could include annual deductible, copays, and coinsurance.
- What additional services are offered (i.e. preventive care, vision, dental, health club membership)
- Any treatments you need that aren’t covered by the plan
How do you enroll in a Medicare Advantage plan?
If you want to enroll in a Medicare Advantage plan, you must:
- Be eligible for Medicare
- Be enrolled in both Medicare Part A and Medicare Part B (you can check this by referring to your red, white, and blue Medicare card)
- Live within the plan’s service area (which is based on the county you live in–not your state of residence)
- Not have end-stage renal disease (ESRD)
Want more information about enrollment? Visit Medicare Part C Eligibility and Enrollment Information