Medicare Advantage: How Part C Works
Another way to receive Medicare-covered benefits
Medicare Advantage, also called Part C, is an alternative way to receive Medicare-covered Part A and Part B benefits. The plans are offered by Medicare-approved private companies and must follow Medicare rules.
To join a Medicare Advantage Plan, you must have Medicare Part A and Part B and live in the plan’s service area. You remain in Medicare and keep Medicare rights and protections.
You continue paying the Part B premium
You must keep paying the Medicare Part B premium to remain in Medicare Advantage. A plan may also charge its own premium, deductible, copayments or coinsurance. These amounts vary by plan and can change each year.
Some plans may help pay part of the Part B premium, but that feature is not available in every plan or area. Check the plan’s current documents rather than assuming a specific cost.
Networks and plan rules vary
Many Medicare Advantage Plans use provider networks, but network rules differ by plan type. HMOs generally require in-network care except for specified situations, while PPOs generally allow out-of-network care at a higher cost. Other plan types work differently.
Plans may use referrals, prior authorization or other coverage rules. Confirm that important doctors, hospitals and other providers participate in the exact plan and verify how out-of-network and prior-authorization rules apply.
Drug coverage is plan-specific
Most Medicare Advantage Plans include Medicare drug coverage, but not all do. Medical Savings Account Plans and some Private Fee-for-Service Plans do not include Part D and may allow a separate Medicare drug plan.
Check the plan’s formulary, pharmacy network, drug tiers and restrictions for every prescription. Do not assume that a drug or pharmacy covered this year will have the same status next year.
Understand the medical out-of-pocket limit
Medicare Advantage Plans have a yearly limit on what members pay for covered Part A and Part B health services. The amount varies by plan and may include different in-network and out-of-network limits.
This medical out-of-pocket limit is not a universal cap on prescription-drug spending. Medicare drug coverage has separate cost-sharing and annual Part D rules.
Review the plan every year
Read the plan’s Evidence of Coverage for detailed benefits, costs and rules. Each fall, review the Annual Notice of Change for changes that take effect in January, including changes to coverage, costs, networks or service area.
Compare the total fit of a plan: providers, prescriptions, pharmacies, expected health-care use, premiums, deductibles, cost sharing, authorization rules, travel needs and any extra benefits important to you.
Frequently asked questions
Do I still pay the Part B premium with Medicare Advantage?
Yes. You must keep paying the Part B premium to stay in Medicare Advantage. A plan may charge an additional premium or may help pay part of the Part B premium, depending on the specific plan.
Does every Medicare Advantage Plan include drug coverage?
No. Most include Part D, but some plan types do not. Check the specific plan before enrolling because joining a separate drug plan can cause disenrollment from some Medicare Advantage Plans.
Are Medicare Advantage plans the same everywhere?
No. Availability, costs, provider networks, drug coverage and plan rules vary by plan, service area and year. Compare current documents for plans available where you live.