If you are already enrolled in Original Medicare, you are eligible to enroll in Medicare Part C, otherwise known as Medicare Advantage. These plans are offered by private health insurance companies and provide Medicare Parts A and B coverage (hospital and medical benefits).

Key Takeaways

  • Medicare Advantage (Part C) is a Medicare supplement plan that covers certain benefits and out-of-pocket expenses that aren’t covered by Original Medicare.
  • There are a variety of Medicare Advantage plans, including HMO, PPO, PFFS, SNP, and MSA plans.
  • Medicare Advantage eligibility is based on your membership in Original Medicare Parts A and B, unless you have End-Stage Renal Disease.
  • You can enroll in a Medicare Part C plan during the Initial Coverage Election or Annual Election periods if you are already enrolled in Original Medicare.

What is a Medicare Advantage Plan?

Typically, Medicare Advantage (Part C) plans cover everything Original Medicare does, including emergency and urgent care. Unlike Original Medicare, however, Medicare Advantage may offer to cover your total out-of-pocket expenses when you receive healthcare. For instance, you might have a lower copayment, coinsurance, or deductible.

Medicare Advantage can also offer additional benefits not included in Original Medicare. Some Medicare Advantage Plans include routine vision, dental, and/or wellness programs. Medicare Advantage Prescription Drug plans will include prescription drug coverage. Hospice care is covered by Original Medicare and hospice benefits continue to be covered by Original Medicare even if you have an Advantage Plan.

Keep in mind that even if you add a Medicare Advantage Plan, you’ll still be paying your Medicare Part B premiums. If you enroll in a Medicare Advantage Plan, however, you cannot purchase a Medicare Supplement Plan (Medigap).

Types of Medicare Advantage (Part C) Plans

It’s important to understand the differences between various Medicare Advantage Plans. Knowing about these subtle differences can help determine which one is best for you.

  • Health Maintenance Organization Plans (HMO) allow you to see participating doctors and other health professionals. This is a good option if your doctor is already in that network because there will most likely be fewer out-of-pocket expenses with network doctors.
  • Preferred Provider Organization Plans (PPO) cover in- and out-of-network providers. This allows you to choose any doctor, which gives you some flexibility. However, Out-of-Network providers must take Medicare Assignment and can charge additional fees above standard Medicare rates. These fees are typically not covered by Medicare.
  • Private Fee-for-Service Plans (PFFS) allow you to pay a specific amount for health care services. The attending doctor must accept the plan’s terms and conditions. If they don’t agree to those terms the Health Plan won’t cover services through that doctor. Additionally, the doctor typically provides services for the negotiated amount, even if it’s less than their usual charge. However, doctors have the option to charge an additional 15% of the negotiated amount for services. It’s known as “Balance Billing” and the cost is typically passed on to the patient.
  • Special Needs Plans (SNP) are designed for individuals with certain special needs. The three SNP plans cover Medicare beneficiaries living in institutions, those who are dual-eligible for Medicaid and Medicare, and those with chronic conditions, such as diabetes, End-Stage Renal Disease (ESRD), or HIV/AIDS. These plans always include prescription drug coverage.
  • Health Maintenance Organization–Point of Service Plans (HMO-POS) cover in and out-of-network health services, but rates typically differ. There are fewer out-of-pocket expenses when you use in-network doctors, labs, hospitals and other health care providers.
  • Medical Savings Account Plans (MSA) are a flexible option for those who like to control their care. They have a high deductible but include regular payments from the government into a savings account that seniors can put towards the healthcare providers of their choice. The amount deposited into the account varies among plans. The money is tax-free as long as it’s used on IRS-qualified medical expenses, which include your deductible.

Eligibility Guidelines

Medicare Part C eligibility is based on your membership in, or eligibility for, Original Medicare Parts A and B (unless you have ESRD). Typically, if you have Medicare Parts A and B, then you’re eligible for Part C. However, you must reside in the service area for the plan you’re considering.

If you have other health insurance coverage, such as through an employer or union, consult with your plan administrator about that the rules before enrolling. You may lose your other coverage if you enroll in the Medicare Advantage Plan and not be able to get it back if you change your mind.

Enrollment Guidelines

There are specified election periods for enrolling in a Medicare Advantage Plan.

Initial Coverage Election Period: You can enroll in Medicare Advantage or Medicare Advantage with prescription drug coverage once you are eligible for Medicare. Your Initial Coverage Election Period (ICEP) is seven months and begins three months before the month you turn 65. It includes the month you turn 65 and ends three months after the month you turn 65. If you aren’t 65 and are receiving Social Security (SS) disability, you qualify for Medicare in the 25th month after you begin receiving your SS benefits. If you fall into this category, you can enroll in a Medicare Advantage Plan three months before your month of eligibility, during that month and three months after. For example, if your Medicare Parts A and B coverage starts in May, your Medicare Advantage IEP is February through August.

Annual Election Period: If you are already enrolled in Original Medicare, you must wait until the next enrollment period to sign up for Medicare Advantage. The Annual Election Period (AEP) runs from October 15 through December 7. The plan coverage you choose during that period starts January 1 of the next year.

Disenrollment: If, after enrolling in a Medicare Advantage Plan, you decide it’s not for you, you can switch back to Original Medicare any time from January 1 through March 31 each year. If you would be losing your prescription coverage, you also can sign up for a Medicare Part D standalone prescription drug plan during that time.

Special Election Period: Generally, once you enroll in Medicare Advantage, you stay enrolled until the next AEP. There are, however, some life events that qualify you for a Special Election Period (SEP) so you can modify your coverage. These life events include (but aren’t limited to):

  • Moving outside your Medicare Advantage Plan’s service area
  • Qualifying for Extra Help (a program to help pay for prescription drugs)
  • Moving into an institution (such as a nursing home)
  • Becoming newly eligible for Medicaid
  • Recently losing Medicaid eligibility

Medicare has neither reviewed nor endorsed this information.

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