What is Medicare Advantage (Part C)?
A private plan that takes over administering your Medicare. Here is how it actually works, what it adds, and what it asks of you in return.
Medicare Advantage, also called Part C, is not extra coverage on top of Medicare. It is a different way of receiving the Medicare you already have.
The mechanics
You enroll in Part A and Part B first. Then you choose a private plan approved by Medicare. From that point the plan administers your care, and Medicare pays the plan a fixed amount each month to do it.
You keep paying your Part B premium. You stay enrolled in Medicare the whole time. What changes is who processes your claims and what rules apply to getting care.
You are not leaving Medicare when you join an Advantage plan. This is the most common misunderstanding about Part C, in both directions. People think they are giving up Medicare, or they think the plan is additional insurance. Neither is right.
What the plan must cover
Every Advantage plan is required to cover everything Original Medicare covers, with the exception of hospice, which stays with Original Medicare even after you join a plan.
Beyond that baseline, plans compete by adding things Medicare does not cover at all.
- Prescription drug coverage, built in on most plans
- Dental, vision and hearing allowances
- Fitness benefits
- Over the counter allowances for pharmacy items
- Transportation to medical appointments on some plans
- In some cases, a credit back toward your Part B premium
What it asks in return
- A network. You use the plan's contracted doctors and hospitals, or pay more, or in some plans have no coverage at all outside it.
- Referrals, on most HMO plans, before you see a specialist.
- Prior authorization on many services, meaning the plan approves the care before it happens.
- Copays as you use care, rather than a large monthly premium.
That last one is the real trade. Instead of paying a supplement premium every month whether you use care or not, you pay when you use care, up to an annual maximum.
The out of pocket maximum
Every Advantage plan has an annual cap on what you can pay for covered in network services. Once you hit it, the plan pays everything for the rest of the year.
Original Medicare by itself has no such cap, which is the single strongest argument for Advantage over going bare. See the full comparison.
The plan types you will see
- HMO. Network only, referrals required, lowest cost, most common.
- PPO. Out of network care covered at a higher cost, more flexibility, usually a higher premium.
- SNP, or Special Needs Plan. Restricted to people with a specific situation, such as being eligible for both Medicare and Medicaid. See dual eligible plans.
Read the HMO and PPO comparison before assuming one is simply better.
Why so many people here have one
Hidalgo County has one of the highest Medicare Advantage participation rates in the country, considerably above the Texas average, with a large number of plans competing and many carrying no additional premium.
Deep local networks are a real part of the reason. When the doctors and hospitals you already use are all inside the network, the main drawback of Advantage largely disappears.
That does not make it right for everyone, and the honest downsides are worth reading before you decide. See the disadvantages of Medicare Advantage.
Common follow-up questions
Am I still on Medicare if I have an Advantage plan?
Yes. You remain enrolled in Parts A and B and keep paying the Part B premium. The plan administers your coverage.
Do I need a Medigap policy too?
No, and you cannot use one. Medigap only pairs with Original Medicare. Holding both is not permitted.
Is hospice covered by my Advantage plan?
Hospice stays with Original Medicare even while you are enrolled in an Advantage plan. That one benefit does not transfer.
Want this looked at properly?
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What are the disadvantages of Medicare Advantage?
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