Medicare Advantage Plans (Part C)

Medicare Advantage plans offer all of the benefits covered under Original Medicare and more. Many plans also include Medicare Part D prescription drug coverage. Depending on residency, there may be several Medicare Advantage plans to choose from including HMO, POS, PPO and PFFS plans.

In all plan types, Medicare beneficiaries are always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if the beneficiaries are in a Medicare Advantage Plan. Medicare Advantage Plans aren’t considered supplemental coverage.

Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage. In addition to the Medicare beneficiary’s Part B premium, you usually pay one monthly premium for the services provided. Medicare pays a fixed amount for a beneficiary’s care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how beneficiaries get services (like whether they need a referral to see a specialist or if they have to go to only doctors, facilities, or suppliers that belong to the plan).

Medicare Advantage Plans include the following:

  • Health Maintenance Organization (HMO) plans have a network of local doctors and hospitals.
  • Point of Services (POS) plans give members the flexibility to go out of the network to receive some health care services.
  • Preferred Provider Organization (PPO) plans provide access to a network of local doctors and hospitals but also allow the flexibility to use physicians or hospitals outside the network. For most of these plans a referral is not needed for specialty care.
  • Private Fee-for-Service (PFFS) plans give the freedom to receive care from any Medicare-approved provider who agrees to accept the plan’s terms and conditions of payment.
  • Medical Savings Account (MSA) Plans.
  • Special Needs Plans (SNP).

Medicare Supplement Insurance Policies

Original Medicare pays for many, but not all, health care services and supplies. A Medigap policy, sold by private insurance companies, can help pay some of the health care costs (“gaps”) that Original Medicare doesn’t cover, like co-payments, coinsurance, and deductibles. Some Medigap policies also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. If a Medicare beneficiary has Original Medicare and they buy a Medigap policy, both plans will pay their share of Medicare‑approved amounts for covered health care costs. Medicare doesn’t pay any of the costs for a Medigap policy.

Every Medigap policy must follow Federal and state laws designed to protect the beneficiary, and it must be clearly identified as “Medicare Supplement Insurance.” Medigap insurance companies can sell a Medicare beneficiary only a “standardized” Medigap policy identified in most states by letters, Plans A through N. All plans offer the same basic benefits but some offer additional benefits, so the beneficiary can choose which one meets their needs.

Medicare Prescription Drug Coverage (Part D)

Medicare offers prescription drug coverage (Part D) to everyone with Medicare. To get Medicare drug coverage, Medicare beneficiaries must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. Medicare Part D plans are available in all 50 states and territories. These plans provide a way to add drug coverage to Original Medicare or Medicare Supplement coverage.

There are two ways to get Medicare prescription drug coverage:
Medicare Prescription Drug Plans.1. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (“PFFS”) Plans, and Medicare Medical Savings Account (“MSA”) Plans.

Medicare Advantage Plans (like an HMO or PPO) or other 2. Medicare health plans that offer Medicare prescription drug coverage. The beneficiaries get all of their Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs”.