Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
Medicare Advantage (MA) Plans, also called Medicare Part C, are the alternative to Original Medicare for your Medicare Part A and Part B coverage. There are different types of MA plans to suit a variety of needs, preferences, and budgets. Availability and costs for MA plans vary depending on the insurer, your location, and your eligibility for the plan.
There are tools and resources available to you to help you compare MA plans, and there are specific enrollment periods when you can sign up or change your plan. Read on to learn how to pick the best Medicare Advantage Plan for you.
What Kinds of Medicare Advantage Plans Are Available?
All MA plans must provide coverage for Medicare Parts A and B benefits, and most plans include Part D prescription drug coverage. MA plans typically include extra benefits that Medicare doesn’t cover, such as vision, hearing, dental, and fitness club memberships. All MA plans include a maximum out-of-pocket limit that you may spend on in and out-of-network Medicare-covered services. MA insurers can set the max limit lower than what CMS requires.
In general, Medicare Advantage Plans provide health care services to you from a network of providers. MA plan options and offerings vary by county.
There are four main types of Medicare Advantage Plans:
- Health Maintenance Organizations (HMOs). The most common type of MA plan requires you to receive all services from in-network providers.
- Preferred Provider Organizations (PPOs). The next most common type of MA plan allows you to receive services from in and out-of-network providers.
- Private Fee-for-Service (PFFS). Allows you to see Medicare providers who accept your plan’s terms and agree to treat you.
- Special Needs Plans (SNPs). Limits membership to people with specific diseases or characteristics. Benefits and care coordination are targeted to meet the needs of the groups they serve.
- Chronic conditions (C-SNP) for people with severe or disabling conditions
- Dual eligible (D-SNP) for people who have Medicare and Medicaid
- Institutional (I-SNP) for people who live in an institution like a nursing home or who need nursing care at home
Two less common types of Medicare Advantage Plans are:
- HMO Point of Service (HMO-POS). An HMO plan that allows you to receive certain services out of network.
- Medicare Medical Savings Account (MSA). Combines a high-deductible Medicare Advantage Plan and a Medicare-funded savings account. You pay for health care expenses out of the savings account and are responsible for remaining out-of-pocket expenses until you meet your MA deductible.
Here is a quick comparison of each type of MA:
|Plan type||Part D coverage||Primary Care Physician (PCP)||Referral for specialist||Out-of-network option|
|Health Maintenance Organization (HMO)||Usually (you cannot purchase standalone Part D drug coverage if you have an HMO)||Yes||Yes||No (only with HMO-POS option)|
|Preferred Provider Organization (PPO)||Usually (you cannot purchase standalone Part D drug coverage if you have a PPO)||No||No||Yes, but you pay more for out-of-network services|
|Private Fee-for-Service Plan (PFFS)||Sometimes (you can purchase standalone Part D drug coverage if you have a PFFS)||No||No||You only use Medicare-approved providers that accept your plan’s terms and agree to treat you|
|Special Needs Plan (SNP)||Yes||Yes, or you may need a care coordinator||Yes||Depends on the plan|
|Medical Savings Account (MSA)||No||No||No||MSAs don’t usually have a network of providers|
What Costs Should You Consider With Medicare Advantage Plans?
There are several costs to consider with a Medicare Advantage Plan, including:
- Monthly premiums. If your MA plan has a monthly premium, you pay it whether or not you access your benefits. Most Medicare beneficiaries in the U.S. have the opportunity to join a zero-premium plan with drug coverage. Some MA plans charge a premium for more comprehensive coverage of extra benefits. You must be enrolled in Medicare Part A and B to join a Medicare Advantage Plan, so you still pay your monthly Part B premium and Part A premium if you have to buy it.
- Deductibles. The amounts you pay before your plan pays for health and/or drug benefits received.
- Copays and coinsurance. Your portion of costs in the form of a set amount (copay) or percentage (coinsurance) for services and drugs received.
- Maximum out-of-pocket limits. The most you may spend (deductibles, copays, and coinsurance) for Medicare-covered Part A and B services in one year. Your monthly premiums or expenses for prescription drugs and extra benefits do not count toward your out-of-pocket max.
Your costs will be lowest if you receive your services and prescription drugs from your plan’s in-network providers and pharmacies. Each MA plan that provides prescription drug coverage (MA-PD) only pays for drugs on its formulary (list of drugs). Generic drugs cost less than brand names or specialty drugs.
For your plan to pay, you must follow your plan’s rules about how you get your benefits. For instance, you may need a referral to see a specialist or prior authorization for a drug or treatment.
There are intangible costs to consider with Medicare Advantage. Health care is potentially a big-budget item, and the kind of service you receive affects your quality of life.
- Anticipate how much health care you may need based on your medical history.
- Think about how important it is to have easy access to the kind of care you want when you need it.
- Are you willing to pay more for out-of-network care if you have more choices of providers?
- Are you planning to travel or spend part of the year in another part of the country?
- How many extra benefits, such as hearing, dental, and vision, do you need?
- Do you qualify for a Special Needs Plan?
Past experience with the health care system may help you formulate your priorities to choose the best Medicare Advantage Plan for you.
How Do You Compare Medicare Advantage Plans?
The best way to compare Medicare Advantage Plans available in your area is to visit Medicare’s online site. You can create an account or continue without signing in. (If you create a personal account, you can save your drug list and won’t have to re-enter it every time you search for a plan).
After you input your zip code and follow a few prompts, you will see a list of MA plans in your area. You can filter your results in the following areas:
- Plan type
- Plan benefits
- Insurance carrier
- Drug coverage
- Star ratings
- Special needs plans.
You can view a side-by-side comparison of up to three plans at a time with a snapshot of costs and benefits. Dig deeper by clicking ‘plan details.’ You can view each plan’s formulary, preferred providers, and rules for how you get your benefits. You can also explore how much you pay in premiums for more comprehensive coverage of extra benefits.
Each plan will have a Star rating , which Medicare gives based on how well the insurer provides preventive care, chronic condition management, and customer service. Member satisfaction and complaints are also factored into the Star rating.
Comparing plans can take some time and effort. While Medicare has a great tool to get you started, you can also seek help from an expert in your local community. Licensed Medicare insurance agents provide free consultations and help you sign up for a plan. Alternatively, you can contact your local Office on Aging or your State Health Insurance Assistance Program (SHIP) to receive unbiased guidance and one-on-one counseling.
Once You Find A Medicare Advantage Plan, How Do You Sign Up?
You must be enrolled in Original Medicare Parts A and B to join a Medicare Advantage Plan. There are specific enrollment periods for MA plans:
- Your Initial Enrollment Period (IEP) for Medicare. The seven-month window starts three months before you turn 65, includes your birthday month, and ends three months later.
- Annual Enrollment Period (October 15 to December 7). Join a Medicare Advantage Plan or switch to a different one.
- Medicare Advantage Open Enrollment Period (January 1 to March 31). Switch from one MA plan to another.
- April 1 – June 30. Join a Medicare Advantage Plan if you had Part A and enrolled in Part B for the first time during the General Enrollment Period (January 1 – March 31).
- Special Enrollment Period (SEP). You may qualify for a special enrollment period if your circumstances change, such as moving or losing employer-sponsored coverage. Rules are different, depending on your circumstance.
- Five-star enrollment period. You can switch to a five-star plan once if it becomes available to you in your area between December 8 and November 30.
When you select your plan, follow the plan’s instructions for completing an enrollment application. Many plans will allow you to fill out the application online, although all plans are required to offer an option for a paper enrollment form.
Or, call 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.
You will need to provide your Medicare number, as well as the date your Medicare Part A and Part B coverage began.
Learn More From Our Sources
- Medicare | Health Maintenance Organizations (HMOs) | Last accessed October 2023
- Medicare | Medicare Advantage Plans | Last accessed October 2023
- Medicare | Find a 2022 Medicare Plan | Last accessed October 2023
- Medicare | 5-Star Special Enrollment Period | Last accessed October 2023
- Medicare | Special Enrollment Periods | Last accessed October 2023
- Medicare | Understanding Medicare Advantage Enrollment Periods | Last accessed October 2023
- Medicare | Evidence of Coverage | Last accessed October 2023
- Medicare | Medicare Medical Savings Account | Last accessed October 2023
- Medicare | Preferred Provider Organizations (PPOs) | Last accessed October 2023
- Medicare | Private Fee-for-Service (PFFS) | Last accessed October 2023
- Medicare | Special Needs Plans | Last accessed October 2023
- National Council on Aging | Find Your Local Office on Aging | Last accessed October 2023
- SHIP | Get Help With Medicare | Last accessed October 2023