Medicare Advantage

A Medicare Advantage Plan is another way to get your Medicare Part A and

Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,”

are Medicare-approved plans. They’re offered by private companies that must follow

rules set by Medicare. Most Medicare Advantage Plans include drug coverage

(Part D). There are several types of Medicare Advantage Plans (go to page 12 for more

information). Each of these Medicare Advantage Plan types has special rules about how

you get your Medicare-covered Part A and B services and any supplemental benefits

your plan covers.

If you join a Medicare Advantage Plan you’ll still have Medicare, but you’ll get most

of your Part A and Part B coverage from your Medicare Advantage Plan, not Original

Medicare. You’ll have the same rights and protections you would have under Original

Medicare.

You must use the card from your Medicare Advantage Plan to get your Medicare-

covered services. Keep your red, white, and blue Medicare card in a safe place because

you may need to show your Medicare card for some services. Also, you’ll need it if you

ever switch back to Original Medicare.

When you join a Medicare Advantage Plan, Medicare pays a fixed amount for your

coverage each month to the private company offering your Medicare Advantage Plan.

However, each Medicare Advantage Plan can charge different out-of-pocket costs and

have different rules for how you get services (like whether you need a referral to use a

specialist or whether you have to go to doctors, facilities, or suppliers that belong to the

plan’s network for non-emergency or non-urgent care). These rules can change each

year. The plan must notify you about any changes before the start of Open Enrollment

for the next year through the Annual Notice of Change, typically mailed to you before

September 30 (Open Enrollment is October 15 – December 7 every year).

Each year, Medicare Advantage Plans set the amounts enrollees must pay for

premiums, deductibles, services, items, and drugs. The plan (rather than Medicare)

decides how much you pay for the covered drugs, items, and services you get. The

plan can only change what you pay once a year, on January 1. You still have to pay

the Part B premium. Most people pay the standard Part B premium amount every

month. To get this year’s standard Part B premium, visit Medicare.gov/basics/costs/

medicare-costs.

When calculating your out-of-pocket costs in a Medicare Advantage Plan, in addition

to your premium, deductible, copayments, and coinsurance, consider:

•The type of health care services you need and how often you get them.

•Whether you go to a doctor or supplier who accepts assignment (if you’re in a

Preferred Provider Organization Plan, Private Fee‑for‑Service Plan, or Medical

Savings Account (MSA) Plan and if your doctor or supplier is out of network).

Assignment means that your doctor, provider, or supplier agrees (or is required

by law) to accept the Medicare-approved amount as full payment for services

Medicare covers.

•Whether your doctors or suppliers are in the plan’s network.

•Whether the plan offers extra benefits (in addition to Original Medicare benefits)

and if you need to pay extra to get them.

•Whether you have Medicaid or get help from your state through a Medicare

Savings Program to pay your Medicare costs. Each type of coverage is called a

“payer.” When there’s more than one payer, “coordination of benefits” rules decide

who pays first.

•The maximum out-of-pocket limit set by your plan, including any maximum out-of-

pocket limits for out-of-network services

Deductible: The amount you must pay for health care or prescriptions before

Original Medicare, your Medicare Advantage Plan, your Medicare drug plan, or your

other insurance begins to pay.

Coinsurance: An amount you may be required to pay as your share of the cost for

benefits after you pay any deductibles. Coinsurance is usually a percentage (for

example, 20%).

Copayment: An amount you may be required to pay as your share of the cost for

benefits after you pay any deductibles. A copayment is a fixed amount, like $30.

Maximum Out-of-Pocket Limit: Plans have a yearly limit on what you pay out of

pocket for services Part A and Part B cover. Once you reach your plan’s limit, you’ll

pay nothing for Part A and Part B services the plan covers for the rest of the year.

There are different types of Medicare Advantage Plans:

•Health Maintenance Organization (HMO) Plan

•HMO Point-of-Service (HMOPOS) Plan

•Preferred Provider Organization (PPO) Plan

•Private Fee-for-Service (PFFS) Plan

•Special Needs Plan (SNPs)

•Medical Savings Account (MSA) Plan

The area where you live might have all, some, or none of these plan types available.

In addition, multiple plans of the same type might be available in your area, if private

companies choose to offer them. To find available Medicare Advantage Plans,

visit Medicare.gov/plan-compare, read your “Medicare & You” handbook, or