Medicare Advantage Plans (Part C)
Medicare Advantage Plans are an alternative way to receive your Part A (Hospital) and Part B (Medical) benefits. Offered by Medicare-approved private insurers, these plans must follow Medicare’s rules and often bundle extra benefits.
Key Features of Medicare Advantage
Comprehensive Coverage
Most plans include Part D (prescription drug coverage) in addition to Parts A & B.
Provider Networks
HMO/PPO networks help keep costs lower. Some plans allow out-of-network care, usually at a higher cost.
Out-of-Pocket Maximum
Every plan sets a yearly cap on what you pay for covered Part A/B services. After you reach it, covered costs are paid 100% for the rest of the year.
Extra Benefits
Many plans add dental, vision, hearing, fitness, and wellness programs not covered by Original Medicare.
Plan Card
Use your Medicare Advantage plan card for services. Keep your red-white-blue Medicare card safe for future use if you switch back.
Common Types of Medicare Advantage Plans
HMO (Health Maintenance Organization)
Use network providers (except emergencies). Referrals may be needed for specialists.
PPO (Preferred Provider Organization)
See in-network or out-of-network providers. Out-of-network care typically costs more.
PFFS (Private Fee-for-Service)
See any Medicare-approved provider that accepts the plan’s terms and payment.
SNP (Special Needs Plans)
Tailored for specific conditions, disabilities, or dual eligibility (Medicare & Medicaid).
Health Maintenance Organization (HMO)
An HMO Medicare Advantage plan is one of the most common ways to get Medicare benefits. These plans are designed to keep costs lower by using a network of doctors, hospitals, and other providers.
Key Features
- Network-Based Care: Generally use in-network doctors and hospitals (exceptions for emergencies/urgent care).
- Primary Care Physician (PCP): Most HMOs ask you to choose a PCP to coordinate your care.
- Referrals for Specialists: Typically required from your PCP to see a specialist.
- Lower Costs: HMOs often have lower premiums and out-of-pocket costs than other plan types.
What’s Included
- All benefits of Medicare Part A (Hospital Insurance) and Part B (Medical Insurance)
- Most HMOs also include Part D prescription drug coverage
- May offer extra benefits such as dental, vision, hearing, or wellness programs
Preferred Provider Organization (PPO)
A PPO Medicare Advantage plan offers more flexibility than an HMO by allowing you to see providers both in-network and out-of-network.
Key Features
- No Primary Care Requirement: You don’t need to choose a PCP.
- No Referrals Needed: See specialists without a referral.
- Flexibility: Use out-of-network providers (you’ll usually pay more).
- Higher Premiums: Often higher than HMOs, in exchange for broader access to care.
What’s Included
- All benefits of Medicare Part A (Hospital) and Part B (Medical)
- Most PPOs also include Part D prescription drug coverage
- May offer extra benefits like dental, vision, hearing, and fitness programs
Private Fee-for-Service (PFFS) Plans
A PFFS Medicare Advantage plan offers flexibility in choosing providers. You can see any Medicare-approved doctor or hospital that accepts the plan’s payment terms.
Key Features
- Any Medicare-Approved Provider: See any doctor or hospital that accepts Medicare and agrees to the plan’s payment terms.
- No Primary Care Requirement: You don’t need to select a PCP.
- No Referrals Needed: Go directly to specialists without referrals.
- Flexibility: Some PFFS plans have a network with lower costs, but you may use non-network providers if they accept the plan’s terms.
What’s Included
- All benefits of Medicare Part A (Hospital Insurance) and Part B (Medical Insurance)
- Some PFFS plans include Part D drug coverage; others may require a separate stand-alone Part D plan
- May offer extra benefits such as dental, vision, or hearing (varies by insurer)
Special Needs Plans (SNP)
Special Needs Plans are Medicare Advantage plans tailored for people with specific health conditions, financial situations, or care needs. Benefits, networks, and drug formularies are designed to match members’ needs.
Key Features
- Targeted Coverage: Available only to people who meet specific eligibility criteria.
- Coordinated Care: Often includes case managers or care coordinators for ongoing treatment.
- Integrated Benefits: Many SNPs combine medical, hospital, and prescription drug coverage with extra benefits.
What’s Included
- All benefits of Medicare Part A (Hospital) and Part B (Medical)
- Part D prescription drug coverage is always included
- Extra, group-specific benefits (e.g., transportation, care coordination, enhanced drug coverage)
Types of SNPs
C-SNP (Chronic Condition)
For people with severe or disabling chronic conditions (e.g., diabetes, heart disease, chronic lung disorders).
D-SNP (Dual-Eligible)
For people who qualify for both Medicare and Medicaid, coordinating both programs’ benefits.
I-SNP (Institutional)
For individuals living in institutions (e.g., nursing homes) or needing nursing care at home.
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