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Medicare Coverage
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Medicare Advantage Plans

A Medicare Advantage (MA) plan is a private insurance plan, also known as Medicare Part C, for individuals who are eligible for Medicare. These plans are optional, however in order to qualify you must be participating in both Medicare Parts A & B. All Medicare Advantage plans must meet the minimum standard benefits offered by Original Medicare (Parts A & B). They generally offer additional benefits such as lower or set co-pays, dental plans, eye exams and other services. These plans are offered as HMO or PPO plans by private insurance carriers. Typically prices and benefits will vary based on your county.

Some Medicare Advantage plans also offer an embedded Part D (Prescription Drug Plan) also known as Medicare Advantage with Part D or MAPD for short. However, keep in mind that not all Medicare Advantage plans have a Part D included. If you select a Medicare Advantage Plan that does not have Part D (MA Only) you cannot purchase a separate Part D plan. You can only have one at a time. Your enrollment in one plan will automatically dis-enroll you from the other!

Types of Medicare Advantage (Part C) plans

It’s important to understand the differences between the types of Medicare Advantage plans to see which works best for you. There are several different types of Medicare Advantage plans:

  • HMO (Health Maintenance Organization Plan): These plans allow you to see providers that are contracted and considered In-Network. Generally they are lower costs and will have set co-pays for common services.
  • PPO (Preferred Provider Organization Plan): These plans allow for more flexibility with your providers as you have access to both In-Network and Out-Of-Network services.
  • PFFS (Private Fee-for-Service Plan) : Pays a specific amount for medical services and your provider has to accept the fee schedule–even if it’s less than their usual charges. If your provider doesn’t agree to those terms than your insurance will not cover services by that provider.
  • SNP (Special Needs Plans): Designed for people who have certain special needs. Special needs include those who are dual-eligible for Medicare and Medicaid, those with chronic conditions such as diabetes, End Stage Renal Disease (ESRD), or HIV/AIDS. Special Needs Plans always include prescription drug coverage.

There are other less common types of Medicare Advantage plans that may be available:

  • HMO-POS (Health Maintenance Organization Point of Service): An HMO plan that allows for some services to be Out-of-network at a higher cost.
  • MSA (Medical Savings Account): Combines a high deductible plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use these funds to help pay for your health care services throughout the year.

Who can join a Medicare Advantage Plan?

Typically you have to meet the following criteria to join a plan:

  • Live in the service area for the plan
  • Must Medicare Parts A and B
  • Must not have End Stage Renal Disease (ESRD)

When can I join a Medicare Advantage plan?

There are many Enrollment Periods that will allow you to join. Your Initial enrollment period when you sign up for Original Medicare is the most common. However, you will also have Annual Enrollment Periods (Oct 15-Dec 7) every year as well as Special Enrollment Periods.

How do I join a Medicare Advantage plan?

  • Use Medicare’s Plan Finder
  • Enroll online
  • Call Us and speak to a licensed agent