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Medicare Advantage Plans - Medicare Part C

Part C refers to the Medicare Advantage program, through which beneficiaries can enroll in a private managed care plan, such as an HMO, PPO, or private fee-for-service (PFFS) plan. These plans offer combined coverage of Part A, Part B and in most cases, Part D (prescription drug) benefits. To join a Medicare Advantage Plan, individuals must have both Medicare Part A and Part B and must continue to pay the monthly Part B premium.

These plans are available in many areas of the country. Some of the plans offer added benefits, like coverage for extra days in the hospital, and some might charge monthly premiums as well as a co-payment for services.

In some Medicare Advantage Plans, you can only go to the doctors, specialists, or hospitals on the plan’s list.

Medicare Advantage Plans must cover at least the same benefits covered by Medicare Part A and Part B, but in most cases, plans cover more services and have lower out-of-pocket costs than the Original Medicare Plan. Once enrolled, all benefits are administered by the Medicare Advantage Plan.

Medicare Advantage Plans include:

-Medicare Health Maintenance Organization (HMO) Plans
-Medicare Preferred Provider Organization (PPO) Plans
-Medicare Private Fee-for-Service (PFFS) Plans
-Medicare Advantage Prescription Drug (MAPD) Plans

Medicare Health Maintenance Organization HMO Plans

A type of Medicare Advantage Plan that is available in some areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Generally, out-of-pocket costs may be lower than in the Original Medicare Plan.

The service area is where the plan accepts members and where plan services are provided. If a beneficiary seeks services outside of the plan’s service area, they may have to pay for those services themselves. Beneficiaries are asked to choose a primary care physician (PCP). In most HMOs, beneficiaries must see their PCP before they can see any other health care provider.

Medicare Preferred Provider Organization (PPO) Plans

Generally in a PPO beneficiaries can see any doctor or provider that accepts Medicare. No referral is needed to obtain services. If services are rendered by “out-of-network” providers, beneficiaries will usually pay higher co-payments.


Medicare Private Fee-for-Service (PFFS) Plans

A private Fee-for-Service Plan is a Medicare Advantage Plan offered by a private insurance company. With a PFFS plan, beneficiaries can go to any primary care doctor, specialist or hospital that accepts Medicare and agrees to the terms of the plan’s payment. Prior authorization or referrals are not required. The private company, rather than the Medicare program, decides how much it will pay and what the beneficiary’s out-of-pocket expense will be.

Medicare Advantage Prescription Drug (MAPD) Plans

A MAPD, also known as Coordinated Care Plan, is a Medicare Advantage plan that also includes Part D prescription drug coverage. Beneficiaries will generally get all of their Medicare-covered health care through the MAPD plan, including prescription drug coverage.

Currently, Medicare Advantage plans (excluding PFFS plans) must offer at least one plan with basic drug coverage or a plan with enhanced alternative drug coverage for no additional premium). Beneficiaries enrolled in a Medicare PFFS Plan that doesn’t offer Medicare prescription drug coverage, can join a Stand-alone Medicare PDP.


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