27.4 Medicare Part C: Medicare Advantage
Key Takeaways
Medicare Advantage replaces Parts A and B through private plans approved by Medicare.
Plan types include HMO, PPO, PFFS, SNP, and MSA designs.
MA plans often include Part D and extra benefits like vision or dental.
Members still pay the Part B premium and may have additional plan premiums.
Enrollment requires Parts A and B and living in the plan's service area.
Cost sharing and networks vary by plan and must follow Medicare rules.
Medicare Advantage (MA), also known as Part C, is an alternative way to receive Medicare benefits through private insurance companies approved by Medicare. These plans combine Part A and Part B coverage, and most include Part D prescription drug coverage (MA-PD plans).
Medicare Advantage Overview
What is Medicare Advantage?
| Feature | Description |
|---|---|
| Administration | Private insurance companies |
| Approval | Must be approved by CMS |
| Coverage | Must cover everything Original Medicare covers |
| Additional benefits | Often includes vision, dental, hearing, fitness |
| Out-of-pocket maximum | Required annual limit on spending |
Medicare Advantage vs. Original Medicare
| Factor | Original Medicare | Medicare Advantage |
|---|---|---|
| Administration | Federal government | Private insurers |
| Provider choice | Any Medicare provider | Usually network-based |
| Referrals | Not required | May be required (HMO) |
| Out-of-pocket max | None | Required |
| Prescription drugs | Separate Part D needed | Usually included |
| Additional benefits | Not included | Often included |
Key Point: To enroll in a Medicare Advantage plan, you must have BOTH Medicare Part A AND Part B and continue paying your Part B premium.
Types of Medicare Advantage Plans
Health Maintenance Organization (HMO)
| Feature | Details |
|---|---|
| Network | Must use plan's network providers |
| Primary care physician | Usually required |
| Referrals | Generally required for specialists |
| Out-of-network coverage | Usually none except emergencies |
| Cost | Typically lower premiums and copays |
Preferred Provider Organization (PPO)
| Feature | Details |
|---|---|
| Network | Has network but allows out-of-network |
| Primary care physician | Not required |
| Referrals | Not required for specialists |
| Out-of-network coverage | Covered at higher cost |
| Cost | Higher premiums than HMO |
Other MA Plan Types
| Plan Type | Description |
|---|---|
| Private Fee-for-Service (PFFS) | Plan determines payment to providers |
| Special Needs Plans (SNP) | For specific populations (dual-eligible, chronic conditions, institutional) |
| HMO Point-of-Service (HMO-POS) | HMO with some out-of-network coverage |
| Regional PPO | PPO covering entire region |
Medicare Advantage Costs
MA plan premiums vary by plan and area; members still pay the Part B premium. Compare current plan costs on Medicare.gov Plan Finder.
Maximum Out-of-Pocket Limits
| Coverage Type | Maximum |
|---|---|
| In-network only | Varies by plan |
| In-network + out-of-network | Higher limit |
| Required by Medicare | Yes (no limit in Original Medicare) |
Exam Tip: The out-of-pocket maximum is a key advantage of MA plans. Original Medicare has NO out-of-pocket limit—you pay 20% coinsurance indefinitely.
Additional Benefits in MA Plans
Commonly Included Benefits
| Benefit | Original Medicare | Many MA Plans |
|---|---|---|
| Routine dental | Not covered | Often included |
| Routine vision | Not covered | Often included |
| Hearing aids | Not covered | Often included |
| Fitness programs | Not covered | Often included (SilverSneakers) |
| Transportation | Not covered | Sometimes included |
| Over-the-counter allowance | Not covered | Sometimes included |
Recent Mental Health Coverage Changes
| Change | Description |
|---|---|
| Expanded providers | Marriage/family therapists and mental health counselors now covered |
| Intensive outpatient | New program bridging outpatient and hospital care |
| Network requirements | Behavioral health network expansion required |
Enrollment and Eligibility
Eligibility Requirements
| Requirement | Details |
|---|---|
| Part A enrollment | Must have Part A |
| Part B enrollment | Must have Part B |
| Continue Part B premium | Still pay $202.90/month in 2026 (or IRMAA amount) |
| Service area | Must live in plan's service area |
| ESRD | People with ESRD can choose Original Medicare or a Medicare Advantage plan |
Enrollment Periods
| Period | Dates | Changes Allowed |
|---|---|---|
| Annual Enrollment Period (AEP) | Oct 15 - Dec 7 | Switch to/from MA, change MA plans |
| Medicare Advantage Open Enrollment (MA OEP) | Jan 1 - Mar 31 | Switch MA plans or return to Original Medicare |
| Initial Enrollment Period (IEP) | 7 months around 65th birthday | Initial enrollment in MA |
| Special Enrollment Period (SEP) | Varies | Qualifying life events |
Disenrollment
| Reason | Options |
|---|---|
| Move out of service area | Change plans or return to Original Medicare |
| Plan leaves Medicare | Automatic enrollment options provided |
| Dissatisfaction | Switch during AEP or MA OEP |
| Plan doesn't meet standards | May have SEP |
Key Point: During the Medicare Advantage Open Enrollment Period (Jan 1 - Mar 31), those already in an MA plan can switch to a different MA plan or return to Original Medicare and add a Part D plan.
Key Takeaways
- Medicare Advantage replaces Parts A and B through private plans approved by Medicare.
- Plan types include HMO, PPO, PFFS, SNP, and MSA designs.
- MA plans often include Part D and extra benefits like vision or dental.
- Members still pay the Part B premium and may have additional plan premiums.
- Enrollment requires Parts A and B and living in the plan's service area.
- Cost sharing and networks vary by plan and must follow Medicare rules.
Which of the following is required to enroll in a Medicare Advantage plan?
Only Medicare Part A
Only Medicare Part B
Both Medicare Part A and Part B
Neither Part A nor Part B
What is a key advantage of Medicare Advantage plans compared to Original Medicare?
No monthly premium required
Access to any doctor in the country
Annual out-of-pocket maximum
No need for prior authorization
During which period can a Medicare Advantage enrollee switch to a different MA plan or return to Original Medicare?
Annual Enrollment Period only (Oct 15 - Dec 7)
General Enrollment Period only (Jan 1 - Mar 31)
Medicare Advantage Open Enrollment Period only (Jan 1 - Mar 31)
Both the AEP (Oct 15 - Dec 7) and MA OEP (Jan 1 - Mar 31)
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