What Is Medicare Advantage (Part C)?

Medicare Advantage, also known as Part C, is an alternative to Original Medicare (Parts A and B) offered by private insurance companies approved by Medicare. These plans combine hospital insurance (Part A) and medical insurance (Part B) coverage, and most include prescription drug coverage (Part D). Medicare Advantage plans often offer additional benefits not covered by Original Medicare, such as vision, dental, hearing, and fitness programs.

What are the benefits of Medicare Advantage?

• Comprehensive coverage: Combines hospital, medical, and often prescription drug coverage.
• Extra benefits: Some plans include dental, vision, and hearing coverage.
• Out-of-pocket maximums: Limits annual spending, unlike Original Medicare.
• Coordinated care: HMO and PPO networks may improve care coordination.

What are the potential downsides?

• Network restrictions: Many plans require in-network providers.
• Prior authorization: Some services need insurer approval before coverage.
• Cost variations: Copays and deductibles can add up, especially for out-of-network care.
• Limited availability: Plan options vary by location and change yearly.
• Switching challenges: Returning to Original Medicare with a Medigap policy isn’t always guaranteed.

How Solace can help

A Solace Medicare advocate can help compare plan options, clarify network rules, secure prior authorizations, and craft appeals for denied claims. They can also find in-network doctors and schedule your appointments. If you're unsure about Medicare Advantage, your advocate can help you weigh the pros and cons based on your healthcare needs.

FAQs About Medicare Advantage (Part C)

How do Medicare Advantage plans differ from Original Medicare?

While Original Medicare is run by the federal government with standard costs and coverage nationwide, Medicare Advantage plans are administered by private insurance companies. This means coverage, costs, networks, and additional benefits vary by plan and location. Medicare Advantage plans typically use provider networks (HMO or PPO models), may require referrals to see specialists, and often include coverage for prescription drugs, vision, and dental care that Original Medicare does not.

When can I enroll in a Medicare Advantage plan?

You can join a Medicare Advantage plan during your Initial Enrollment Period (when you first become eligible for Medicare), during the Annual Enrollment Period (October 15–December 7 each year), or during the Medicare Advantage Open Enrollment Period (January 1–March 31 each year). Special Enrollment Periods may also apply in specific circumstances, such as moving to a new service area or qualifying for Medicaid.

What types of Medicare Advantage plans are available?

Medicare Advantage plans come in several formats, including Health Maintenance Organizations (HMOs) that require you to use network providers and get referrals for specialists; Preferred Provider Organizations (PPOs) that allow you to see any doctor but charge less for in-network care; Private Fee-for-Service (PFFS) plans that determine how much they'll pay providers; Special Needs Plans (SNPs) for people with specific diseases or characteristics; and Medical Savings Account (MSA) plans that combine a high-deductible plan with a medical savings account.

Do I still pay Medicare premiums with a Medicare Advantage plan?

Yes, you must continue paying your Medicare Part B premium when enrolled in a Medicare Advantage plan. In addition to this, some Medicare Advantage plans charge an additional monthly premium, while others have $0 premiums. Even with a $0-premium plan, you're still responsible for the standard Part B premium. Other costs may include deductibles, copayments, and coinsurance that vary by plan.

How do I choose the right Medicare Advantage plan for my needs?

To choose the right Medicare Advantage plan, consider your healthcare needs, budget, and preferences. Compare plan premiums, deductibles, copayments, and coinsurance. Check if your current doctors and hospitals are in-network. Review the plan's drug formulary if you need prescription coverage. Consider any additional benefits like dental or vision care. Use Medicare's Plan Finder tool at Medicare.gov or work with a licensed insurance agent to compare options in your area.

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