Medicare Advantage (Part C) Explained
From costs, healthcare provider options to extra perks and benefits—there are so many factors to consider when choosing a Medicare health plan that works best for you. In fact, on average seniors will have a choice of more than 21 plans, although at least 40 plans will be accessible in some counties and large metropolitan areas.
All of this information can be very overwhelming and confusing. Don't worry. We're here to help navigate Medicare Advantage plans (Part C) for you and make your Medicare journey a smooth one. Let's get started!
Choosing a plan requires you to consider your health, risk tolerance, budget, lifestyle, and other personal circumstances. One option that's often the most popular choice for Medicare beneficiaries is a Medicare Advantage plan (Part C), which is an alternative to traditional or Original Medicare.
In 2020, more than one-third (36%) of all Medicare beneficiaries – 24.1 million people out of 67.7 million Medicare beneficiaries overall – receive health benefits through a Medicare Advantage plan. These numbers show that a Medicare Advantage plan is a popular choice for anyone looking for extra services and coverage that's more affordable than Original Medicare due to capping out-of-pocket costs. Medicare Advantage plans are designed to help you get the most out of your Medicare coverage and include all the benefits of Original Medicare.
Once you retire at 65 years old or later, you'll have several options for health plans, including Original Medicare (Part A and Part B) on its own, a Medicare Supplement (Medigap) plan, or a Medicare Advantage (Part C) plan. When making an important decision such as choosing the most appropriate and affordable healthcare coverage, it's essential that you compare your options and learn about the advantages of each plan.
Although the majority of people with Medicare receive their health coverage from Original Medicare Part A and Part B, others choose to receive their benefits from a Medicare Advantage plan. Original Medicare beneficiaries are responsible for 20% of healthcare costs, or 20% coinsurance, for common health services like office visits or outpatient surgery. Most Medicare Advantage plans use copays instead of coinsurance for these services, which means you pay a fixed cost.
Medicare Advantage plans offer affordable, all‑in‑one solutions.
Medicare Advantage plans are a type of Medicare health plan that combines the coverage of Original Medicare Part A and Part B, including extra benefits that aren't available with Medicare on its own. The plans are commonly called Part C of Medicare, replacement plans, or Medicare private health plans. Medicare Advantage plans are offered by private health insurance companies that have to be approved by Medicare. Medicare Advantage plans are contracted with the federal government and are paid a fixed amount per person to provide Medicare benefits.
What Do Medicare Advantage Plans Cover?
Now that you have a better understanding of what Medicare Advantage plans are, you may be wondering what they actually cover. Let's review what Medicare Advantage plans cover, including some of the plans' benefits.
Legally, Medicare Advantage plans must cover all of the services and benefits that Original Medicare covers. Once you're enrolled in a Medicare Advantage plan, Original Medicare will continue to cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. Medicare Advantage plans combine coverage for hospital care, doctor visits, and other medical services all bundled in one plan.
There are many benefits to Medicare Advantage plans. The plans can include additional coverage options such as routine vision or dental benefits, health wellness programs, or transportation to and from doctor's appointments.
Also, most Medicare Advantage plans offer you the option to get your prescription drug benefits (Medicare Part D) included under the same plan rather than having to enroll in a separate stand-alone Medicare prescription drug plan. Medicare Advantage Drug Plans offer the convenience of including your Medicare Part A, Part B, and Part D coverage through a single plan.
When you're enrolled in a Medicare Advantage plan, most of your Medicare services are covered through the plan. When you join a Medicare Advantage plan, you're making the decision to choose to receive your benefits from a private company for the rest of the calendar year rather than opting to only enroll in Original Medicare. You're always able to make the decision to return to Original Medicare during a valid election period.
How Much Does a
Medicare Advantage Plan Cost?
We want you to be able to plan a smooth, enjoyable retirement. One of the best ways to do so is to understand what you can expect to pay out-of-pocket for a Medicare Advantage plan.
Costs and coverage details for Medicare Advantage plans vary depending on the county or region that you live in, as well as the insurance company. The company that offers the Medicare Advantage plan sets the monthly premium and decides on the cost-sharing amounts. Many Medicare Advantage plans have a $0 premium.
All Medicare Advantage plans have an annual limit on your out-of-pocket costs for covered healthcare services. It's important to note that the limit can change each year and may vary for different Medicare Advantage plans.
According to the U.S. Centers for Medicare & Medicaid Services (CMS), the average Medicare Advantage premiums for 2021 is $21 per month, down from $23.63 in 2020. Average Medicare Advantage premiums have been declining for the last several years, and the average premium for 2021 is the lowest it's been since 2007.
To learn more about Medicare Advantage plans, including how you can enjoy all the security of Original Medicare plus valuable added benefits, contact us to be connected with Time for 65's partnered licensed agents. Your licensed agent will help you choose from a variety of Medicare Advantage plans that are designed to ensure you get the most out of your Medicare coverage.
Medicare Advantage plans are offered through private insurance companies and include medical and hospital coverage, as well as additional coverages and perks. If you're already enrolled in Medicare Part A and Part B, you qualify for a Medicare Advantage plan.
Most Medicare Advantage plans offer the following:
- Hospital coverage: Hospital visits, nursing facility stays, home healthcare, and hospice care
- Medical coverage: Preventive, diagnostic, and treatment-related services
- Prescription drug coverage
- Dental, vision, and hearing coverage
- Additional health perks such as fitness memberships
What are the Most Common Types of Medicare Advantage Plans?
- HMO
- PPO
- PFFS
- SNPs
- Other
Health Maintenance Organization (HMO) Plans
A Health Maintenance Organization (HMO) plan is a type of Medicare Advantage Plan (Part C) that usually limits coverage to care from a network of doctors and hospitals who work for or contract with the HMO. Generally, HMO plans require that you get your care and services from providers in the plan's network, except emergency care, out-of-area urgent care, and out-of-area dialysis.
These plans have strict guidelines, including requiring you to live or work in its service area to be eligible for coverage. If you use a provider who is outside of the plan's network, you may be responsible to pay the full cost out of pocket (except for emergency or urgent care).
HMO plans often provide integrated care and focus on prevention and wellness. To see a specialist, HMOs generally require a referral from your primary care physician. In most cases, prescription drugs are covered in HMO plans.
To put it simply:
An HMO plan is a type of Medicare Advantage plan that includes affordable, fixed costs, and offers all the benefits of Original Medicare, as well as some added features.
- HMO plans typically require you to receive healthcare services from a network of local providers
- Most annual screenings are covered at no charge
- HMO's predictable copayments help to manage an easier budget
- Affordable monthly plan premiums; $0 premium on some plans in some areas
- Emergency coverage anywhere in the world
- Hospitalization coverage
- Membership in the SilverSneakers® fitness program (available on most plans)
Preferred Provider Organization (PPO) Plans
A Preferred Provider Organization (PPO) plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. Unlike HMO plans, in most cases, you're able to receive your healthcare from doctors, hospitals, or other healthcare providers outside of the plan's network. Although it will usually cost more, each PPO plan provides flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list. However, you pay less if you choose doctors, hospitals, and other healthcare providers that belong to the plan's network.
In most cases, prescription drugs are covered in PPO plans. Moreover, in most cases, you don't have to get a referral to see a specialist in PPO plans. It's also important to note that PPO plans usually offer more extra benefits than Original Medicare, but you may have to pay extra for these benefits.
To put it simply:
A PPO plan is a type of Medicare Advantage plan that provides you with the freedom to choose any doctor or hospital that accepts Medicare, and you pay less for services received from in-network providers.
- Ability to choose from any doctor or hospital (with most plans)
- Referrals to specialists are not required
- Affordable copayments for doctor visits and annual routine physicals
- Most annual preventative screenings are covered at no charge
- In-network home healthcare
- Optional fitness programs and prescription drug, vision and dental coverage for additional premiums
- Emergency coverage when you travel outside the U.S.
Private Fee-for-Service (PFFS) Plans
A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan (Part C) offered by a private insurance company. A PFFS plan allows you the freedom to visit any Medicare-approved doctor or hospital as long as the plan's terms and conditions of payment are accepted by the provider. Unlike Original Medicare or Medicare Supplement plans, a PFFS plan determines how much it will pay doctors, hospitals, and other healthcare care providers, as well as how much you're required to pay when you receive your healthcare services.
To put it simply:
A PFFS plan is a type of Medicare Advantage plan that allows you the freedom to receive healthcare services from any Medicare-eligible doctor or hospital that accepts the plans' terms and conditions of payment.
- No referrals are ever needed
- Provides an affordable monthly plan premium
- Most annual preventative screenings are covered at no charge
- Prescription drug coverage on most plans
- Hospitalization coverage
- Emergency coverage anywhere in or out of the U.S.
Special Needs Plans (SNPs)
Special Needs Plans (SNPs) are a type of Medicare Advantage Plan (Part C) that limits enrollment to beneficiaries who have certain chronic conditions, are institutionalized, or qualify for both Medicare and state Medicaid (also known as dual eligibles). SNPs combine all the benefits of Original Medicare (Part A and Part B) with prescription drug coverage (Part D).
SNPs are only available to beneficiaries who have an additional qualifying condition. Depending on the specific SNP, benefits may include coverage for routine dental, vision and hearing care; nonemergency transportation to and from medical care; fitness programs; an over-the-counter medication allowance, and more.
You can join a Medicare SNP if you meet these requirements:
You have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance)
You live in the plan's service area
You meet the plan's eligibility requirements, including:
- Chronic Condition SNP (C-SNP): You have one or more of these severe or disabling chronic conditions:
- Chronic alcohol and other dependence
- Autoimmune disorders
- Cancer (excluding pre-cancer conditions)
- Cardiovascular disorders
- Chronic heart failure
- Dementia
- Diabetes mellitus
- End-stage liver disease
- End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
- Severe hematologic disorders
- HIV/AIDS
- Chronic lung disorders
- Chronic and disabling mental health conditions
- Neurologic disorders
- Stroke
- Institutional SNP (I-SNP): You live in an institution (like a nursing home), or you require nursing care at home.
- Dual Eligible SNP (D-SNP): You have both Medicare and Medicaid.
To put it simply:
An SNP is a type of Medicare Advantage plan that combines all the benefits of Original Medicare (Part A and Part B) with prescription drug coverage (Part D). The plan is only available to those beneficiaries who have an additional qualifying condition.
Other Plans
Other less common types of Medicare Advantage Plans that may be available include HMO Point of Service (HMO-POS) Plans and a Medicare Medical Savings Account (MSA) Plan.
How Do I Qualify for a Medicare Advantage Plan?
So, now you may be wondering, how do I qualify for a Medicare Advantage plan? For starters, you must already be covered by Original Medicare Part A and Part B to join a Medicare Advantage plan. You also must live in the Medicare Advantage plan's service area. Below we'll cover qualifications for a Medicare Advantage plan in more detail.
Although Medicare Advantage plans are offered by private insurance companies, qualifying for a Medicare Advantage plan is similar to qualifying for Original Medicare Part A and Part B. To be eligible for Medicare Part A and Part B, you must be a United States citizen or a permanent legal resident for at least five continuous years. You must also meet at least one of the following criteria for Medicare eligibility:
- Be age 65 or older and eligible for Social Security
- Permanently disabled and receive disability benefits for at least two years
- Have end-stage renal disease (ESRD) (permanent kidney failure that requires dialysis treatment or a kidney transplant)
- Have Lou Gehrig's disease (Amyotrophic Lateral Sclerosis, or ALS)
Once you're eligible for Part A and Part B, you then qualify for Medicare Advantage. Additionally, you must live within the Medicare Advantage plan's service area. Once you find a plan that meets your personal preferences, lifestyle, and/or budget, it's important that you make sure the plan serves the county where you live. If you live in another state for part of the year, ask Time for 65's partnered licensed agents if the plan will cover you there.
There are certain cases where you may not qualify for Medicare Advantage plans. For instance, if you have ESRD you may not qualify for most Medicare Advantage plans. ESRD is a permanent kidney failure that requires you to get dialysis regularly or have a kidney transplant.
There are options for those who have ESRD and still want to enroll in a Medicare Advantage plan, including:
- Contact Time for 65's licensed agents to ask if your specific situation disqualifies you for a Medicare Advantage plan.
- If there is a Special Needs Plan (SNP) in your area, you may qualify for one that is specifically designed for people with ESRD.
What are the Medicare Advantage Plan Enrollment Periods?
For a lot of people, the enrollment systems for different Medicare plans can be overly complicated and complex. We've simplified and clarified Medicare Advantage enrollment periods for you.
If you're thinking about signing up for a Medicare Advantage plan or switching from one plan to another, there are limited time periods when you can make these changes.
The following are important points to note regarding the Medicare Advantage plan enrollment period:
- The annual Medicare open enrollment period begins October 15 and ends December 7.
- The Medicare Advantage Open Enrollment Period runs from January 1 – March 31 every year.
- When you're first eligible for Medicare, you get an Initial Enrollment Period. During this period, you can enroll in Medicare Part A and Part B, or when you're automatically enrolled. You can also decide to get your Part A and Part B benefits from a Medicare Advantage plan.
- In certain cases, you might qualify for a Special Enrollment Period to sign up for a Medicare Advantage plan. Generally, this period is for those who lose coverage – for example, by moving out of the plan's service area.
- There is a designated time where you can't join a Medicare Advantage plan for the first time.
- You can switch between plans if already in a Medicare Advantage plan. You're also able to drop your Medicare Advantage, return to Original Medicare, and then sign up for a stand-alone Medicare Part D prescription drug plan.
- Generally, you can't make other coverage changes during this period.
Are There Extra Perks and Benefits of Medicare Advantage Plans?
Everyone loves extra perks and benefits regardless if it's a free cup of coffee from your favorite barista or a deeply-discounted massage from your go-to masseuse. Luckily, Medicare Advantage plans offer you a wide variety of extra perks and benefits that go beyond Original Medicare.
A great feature of Medicare Advantage plans is that they offer benefits and features that Original Medicare does not offer. In addition to Medicare Part A (hospital stays), Medicare Part B (doctor visits), and Medicare Part D (prescription drug coverage), examples of additional plan perks and benefits include:
$0 doctor visit copays
$0 copays on all primary care provider visits, including rewards for preventative care.
$0 prescription copays
$0 copays on most common prescriptions, including more than $150 in free health and wellness products.
Free dental exams
$0 copay on annual preventive dental exams. Dental benefits cover services such as exams, annual x-rays, cleanings, and fluoride for a $0 copay with in-network dentists.
Free vision exams
$0 copay on annual preventive vision exams, plus free designer eyewear. Many plans also include an eyewear allowance on contacts or frames, with lenses covered in full.
Free hearing exams
$0 annual hearing exams and low copays on name brand and private-label hearing aids.
Free gym membership
Free gym memberships are offered to support your body, mind, and overall health-related goals.
OTC (Over-the-Counter)
The benefits offered help save at least 40% on OTC medications and products.
Virtual medical appointments through preferred telehealth partners
Live chat with a designated telehealth provider from the comfort of your home using your computer, tablet, or smartphone.
Personalized customer service and support
Time for 65's partnered licensed agents are available to help you choose and use your Medicare plan based on your personal preferences, budget, and/or lifestyle. The licensed agents are available online or over the phone.
What are Examples of Questions to Ask When Choosing a Medicare Advantage Plan?
When choosing a Medicare Advantage plan that meets your personal preferences, lifestyle, and/or budget, there are questions you should ask Time for 65's partnered licensed agents to ensure the plan meets these various factors. Here are some examples of questions to ask when speaking with the licensed agents that are partnered with Time for 65:
- Does the plan cover any services that Original Medicare does not?
- Dental services
- Vision care
- Hearing aids
- What are some of the additional perks the plan has to offer?
- Does the plan meet my long-term healthcare needs?
- Does the plan meet my monthly and yearly budget for healthcare?
- What costs should I expect for my coverage (premiums, deductibles, copayments)?
- Will I be able to use my preferred doctors? Are they in the plan's network?
- If my providers are not in-network, will the plan still cover my visits?
- Which specialists, hospitals, home health agencies, and skilled nursing facilities are in the plan's network?
- Are my prescriptions on the plan's formulary?
- What costs should I expect to pay for my drug coverage (premiums, deductibles, copayments)?
- How much will I have to pay for brand-name drugs? How much for generic drugs?
- How does the plan work with my current coverage?
How Do I Enroll in a Medicare Advantage Plan?
The first step to enrolling in a Medicare Advantage plan is confirming whether you're enrolled in both Medicare Part A and Part B. Once you've confirmed enrollment, you can enroll in a Medicare Advantage plan during your Initial Enrollment Period (IEP). Your IEP is a seven-month time span that includes the three months before the month you turn 65, your birthday month and the three months after your birthday month.
If you don't enroll in a Medicare Advantage plan during your IEP, you may have to wait to enroll during the Medicare Annual Enrollment Period, which is October 15 – December 7. Time for 65's partnered licensed agents can assist you with enrolling directly with the private insurance company that offers the Medicare Advantage plan you choose.
One way to compare researching, choosing, and enrolling in a Medicare Advantage plan is planning a vacation with your loved ones and friends. When planning a vacation, you have many all-inclusive options that take care of your travel, hotel, meals, and drinks for one price. This way, you're able to spend more quality time with travel buddies rather than sorting through all the details. Choosing a Medicare Advantage plan is just the same.
If you're interested in more information about affordable, all-in-one Medicare Advantage solutions, including plan eligibility and enrollment, costs, coverage, plan types, and more, feel free to fill out the form or give us a call anytime to get your free quote and ask any questions that may be lingering. We guarantee you that your licensed agent is focused first and foremost on providing you with information with zero pressure to enroll in a plan.
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