Medicare Advantage Plans are often called Medicare Part C or Medicare Health Plans. These plans are run like managed-care health plans (HMOs, etc.) and are offered by private health insurance companies that sign a contract with Medicare. Medicare pays a set amount of money to these companies to administer your health care. You may have to pay an additional premium and continue to pay the Medicare Part B premium.
If you enroll in a Part C plan, you must obtain services from a designated network of doctors, hospitals and other health care providers who have agreed to provide services for plan enrollees. The plan may have a limited service area and you must live within that service area to enroll.
Generally, if you receive treatment outside the network of providers, you probably will be responsible for paying the entire bill unless the service is for emergency or urgently needed care. A primary care physician (PCP) controls your access to other services. Part C plans have co-payments for some services.
There are several variations, all based on managed-care models, available as Part C plans:
- Under a Medicare Managed Care Plan (which is most like a standard HMO), you are seen by doctors in the plan’s network. A primary care doctor coordinates your health care. And there’s usually no additional monthly premium—other than the Medicare Part B premium you have to pay anyway.
- Under the Private-Fee-For-Service (PFFS) option:
- You continue to pay your Medicare Part B premium.
- Premiums vary for the private fee-for-service plan.
- Some services may have co-payments.
- You are eligible if you have Medicare Part A and Part B and live in the plan’s service area and do not have End-Stage Renal Disease (ESRD).
- You may see any provider who accepts Medicare and who will accept the private fee-for-service plan.
- Medicare Preferred Provider Organization Plans (PPOs) are among the most common and popular Part C options. In a Medicare PPO you:
- Don’t need referrals to see a specialist provider out-of-network. You may need plan approval before you get certain services in and/or out-of-network.
- Can see any doctor or provider that accepts Medicare. However, if you go to doctors, hospitals, or other providers who are not part of the plan, you may pay more.
- You continue to pay your Medicare Part B premium and PPO premium.
- Co-payments apply to some services and some services.
- Medicare Special Needs Plans are specially designed for people with specialized health needs. These plans must provide all Medicare Part A and Part B health care and services. They also must provide Medicare prescription drug coverage. These plans have special rules for enrolling. You must have Medicare and Medicaid and not have ESRD (end stage renal disease).
Note: If you have a Medigap policy and you are switching from Medicare to a Medicare Advantage Plan, you do not need the Medigap policy. It cannot be used to cover deductibles, copayments, or coinsurance under the Medicare Advantage Plan. You must cancel the Medigap policy yourself.