Part C

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Part C –   Medicare Advantage

Also known as Medicare Part C, Medicare Advantage Plans are operated by private insurance companies that are contracted by the government. The government pays a fixed fee to your plan for your care, and your plan then pays your doctors and hospitals.

Medicare Advantage plans combine the coverage of Medicare Parts A and B (sometimes called “Original Medicare”) and usually include additional benefits. Most plans include Medicare Part D prescription drug coverage, but not all.. Please keep in mind that Medicare Advantage plans may or may not be available in your area.

There are four main types of Medicare Advantage plans:

  • Health Maintenance Organization (HMO)
    You receive services from a plan’s network of local doctors and hospitals who work together to provide care.
  • Point-of-Service (POS)
    A type of HMO plan that also lets you receive certain services outside the plan’s network, generally at a higher cost to you.
  • Preferred Provider Organization (PPO)
    You can visit in-network and out-of-network doctors and hospitals, but services outside the plan’s network will typically cost more.
  • Private Fee-for-Service (PFFS)
    These are typically non-network plans. You can receive care from any doctor or hospital as long as they agree to accept the plan’s payment terms and conditions.

Are there limits to coverage?
Coverage limits vary by plan, so you’ll have to look at the specific Medicare Advantage plan’s details to see if there are any coverage limits or exclusions.

Plans that include prescription drug coverage may have additional restrictions, such as the cost-sharing amounts you pay for your medications.

What doctors can I see?
This also varies by plan and fewer physicians are in the Medicare Advantage networks. In some plans (like HMOs), your health care is coordinated through a primary care physician, who manages the care you receive from doctors, specialists and hospitals within the plan’s network. With these plans, only the services you receive from network providers are covered.

POS and PPO plans are also coordinated care plans like HMOs, but these plans let you receive covered services outside of the plan’s network, generally at a higher cost to you.

Non-network plans (similar to most PFFS plans) let you receive care from any Medicare-eligible doctor or hospital that accepts the plan’s payment terms and conditions before providing you with care. No referrals are ever needed.

All of these Medicare Advantage plan types offer nationwide coverage for emergency care and urgent care. In these situations, you can go to the nearest doctor or hospital.