A Medicare Advantage (MA) plan, also known as a Part C plan, is another way to get Medicare coverage. Private insurance companies typically offer these plans. Medicare Advantage plans often include prescription coverage (Part D) and additional benefits.
With original Medicare, you don’t need a primary care provider (PCP) and usually don’t need referrals to see specialists. But a Medicare Advantage HMO plan typically selects a PCP for you, and specialist visits usually require a referral.
Another difference is that Medicare Advantage plans will work with a network of healthcare professionals. You may want to check to make sure your doctor is in the network of the MA plan you choose.
No. To join a Medicare Advantage plan, you must:
- be eligible for original Medicare
- live in the service area of the plan you’re interested in joining
- be a U.S. citizen
To be eligible for original Medicare, you should be either 65 or older, disabled, or have end-stage renal disease.
Each company that offers a MA plan will have its own service areas, so it’s best to check with your preferred plan to see whether they cover your area.
A Medicare Advantage plan can also provide additional benefits for services that original Medicare doesn’t cover, including:
- over-the-counter (OTC) drugs
- gym memberships
- transportation to doctor’s visits
It’s also common for a Medicare Advantage plan to cover some vision, hearing, and dental services, which original Medicare doesn’t cover.
The importance of these benefits depends on your healthcare needs and preferences.
Depending on the type of MA plan you enroll in (HMO, PPO, PFFS, SNP), you may have preferred doctors and other healthcare professionals who are considered in network. If your plan has a network, you can save money by seeing an in-network healthcare professional.
To see whether your current doctor participates in your plan, check your health plan’s website or call your doctor. You can also contact the professional directly to ask what insurance they take.
Lastly, Medicare has a comparison tool that can help you see who takes Medicare in your area.
The cost associated with Medicare Advantage plans can vary. Some plans may have a premium, while others may not.
Plans will also range in the total out-of-pocket cost you’ll be responsible for. It’s not unusual for plans to also have a coinsurance or copay for the services you use.
Lastly, since Medicare Advantage typically includes drug coverage, you’ll also want to consider those copays.
Yes. Medicare Advantage plans can have different drug coverage and copay structures.
Medicare offers a tool to help you see which MA plans cover your current medications. You can enter in the names of the medications you take to get an idea of coverage and cost.
You can also check and see whether your pharmacy participates in the health plan you’re considering.
Yes. The Centers for Medicare and Medicaid Services (CMS) collect data to grade a health plan’s performance.
The star ratings range from one to five stars, with five being the best. You can enroll in a five-star plan at any time.
The plan’s star rating is available on Medicare’s Find Health and Drug plan tool for easy comparison.
When shopping for a Medicare Advantage plan, it’s important to prioritize the benefits of care you need most.
Once you’ve found a few plans that meet your needs, you can compare costs and star rating.
Medicare offers tools to help you compare plans in your area. In addition, you can also get information from the health plan’s website or by speaking to a representative.
Dr. Alexandra Perez is a geriatric pharmacist specializing in chronic disease state management. She has experience collaborating with healthcare providers in primary care clinics, optimizing medication regimens. She also has experience in clinical informatics partnering with pharmaceutical companies to help them leverage real world clinical data to perform research studies.