Medicare Advantage
What is Medicare Advantage? A Guide to Medicare Part C
Medicare Advantage, also known as Medicare Part C, consists of Medicare plans provided by private insurance companies approved by the Centers for Medicare & Medicaid Services (CMS). By law, these plans must offer benefits that are equal to or better than Original Medicare (Medicare Part A and Part B). Many Medicare Advantage plans also include prescription drug coverage (Medicare Part D), allowing enrollees to conveniently access a range of healthcare services through a single, comprehensive plan.
Additional Benefits Offered by Medicare Advantage
Depending on your location, some Medicare Advantage plans may offer extra benefits beyond standard Medicare coverage, including:
- Vision care
- Routine dental and/or hearing services
- Allowances for eligible members to assist with costs related to:
Note: Availability of these benefits varies by plan and service area. Not all areas will have a plan that includes every benefit.
Cost-Saving Features
Many Medicare Advantage plans offer low monthly premiums and can help you save on:
- Copayments
- Coinsurance
- Deductibles for eligible members to assist with costs related to:
Special Supplemental Benefits for the Chronically Ill (SSBCI)
Certain plans may provide Special Supplemental Benefits for members with specific chronic conditions. These benefits are available to individuals at high risk for hospitalization or who require intensive care coordination. Qualifying conditions may include (but are not limited to):
- Diabetes mellitus
- Cardiovascular disorders
- Chronic lung disease
- Chronic heart failure
- Chronic and disabling mental health conditions
Meeting the criteria for a qualifying condition does not guarantee eligibility for these additional benefits. Further requirements may apply. For complete details, refer to your plan’s Evidence of Coverage.
Important Considerations
Medicare Advantage offers a comprehensive healthcare solution covering doctor visits, outpatient services, hospital care, and more. While these plans provide extensive coverage, services deemed medically unnecessary may not be covered. If you’re unsure whether a service is included, it’s best to confirm with your provider beforehand.
For personalized guidance and to explore your options, speak with a licensed insurance agent who can help you understand plan details and eligibility.
Understanding Medicare Advantage Networks
Medicare Advantage Plans generally operate through specific networks to manage your healthcare services. The most common networks include HMO, PPO, PFFS, HMOPOS, and MSA. Here’s a breakdown of how each network works:
Key Advantages of Medicare Advantage
- Includes coverage for Medicare Parts A and B
- Access to additional benefits such as vision, dental, and hearing coverage*
- May have lower out-of-pocket costs than Original Medicare
- Prescription drug coverage
- Access to health and wellness programs
- All-in-one convenient plan
What do Medicare Advantage Plans Cover?
Medicare Advantage plans cover a wide range of services for new and existing enrollees seeking convenient, well-rounded coverage. These include benefits not offered by Original Medicare, such as vision, hearing, and dental services as well as non-emergency care.
Medicare Advantage vs. Medicare Supplement:
| AREA OF COMPARISON | MEDICARE ADVANTAGE | MEDICARE SUPPLEMENT |
|---|---|---|
| Coverage | Covers all services under Medicare Parts A & B, and may offer additional benefits. | Covers specific out-of-pocket costs not covered by Medicare, such as deductibles, coinsurance and copays |
| Cost | Offers lower, or sometimes no monthly premiums. | Features consistent monthly premiums although these are often more expensive. |
| Provider Network | Enrollees are limited to a provider network for coverage, with no coverage outside the U.S. | Enrollees may see any provider who accepts Medicare. |
| Prescription Drug Coverage | Most Medicare Advantage plans include prescription drug coverage. | Does not cover Prescription Drug Plans; must enroll in Medicare Part D. |
Is Medicare Advantage Right for Me?
Deciding if Medicare Advantage is the right choice depends on your healthcare needs, lifestyle, and budget. It is essential to evaluate the specific services you require and compare them with the coverage options available. If you are unsure which plan best fits your needs, a licensed DMV Senior Benefits insurance agent can guide you through the process and help you make an informed decision with confidence.
Frequently Asked Questions About Medicare Advantage Plans
Am I eligible for a Medicare Advantage Plan?
Are enrolled in Parts A and B at time of application
If you are age 65 or older
You’re a U.S. citizen or lawfully reside in the service area of the plan you wish to join
If you have End-State Renal Disease or ALS
Can I get Medicare Advantage if I have employer coverage?
What costs are associated with Medicare Advantage plans?
Note that even with a $0 premium Medicare Advantage plan, you’ll still pay a monthly premium for Part B, and a Part D premium if your Medicare Advantage plan does not include prescription drug coverage (MA-PD).
What should I do if I’m eligible for both Medicare and Medicaid?
If this applies to you, Medicare will typically be your primary insurance and Medicaid will be your secondary insurance. Medicare covers most of your health care costs and Medicaid will cover the remaining costs that Medicare does not cover.
Can I switch from a Medicare Advantage plan to Medicare Supplement?
If you pass medical underwriting, you can enroll during enrollment periods during the year, including Fall Open Enrollment (Oct 15 to Dec 7) or Medicare Advantage Open Enrollment (Jan 1 to March 31).
