Medicare Part C Medicare Advantage

Medicare Part C – Medicare Advantage Plans Explained

Are you considering enrolling into a Medicare Advantage Plan? Sometimes known as "Medicare Replacement plans", they cover what Medicare covers and more! All bundled into one plan with one ID card. Medicare Advantage Plans are the alternative coverage option to Original Medicare. The government pays money to private insurance companies to provide your Medicare coverage; essentially outsourcing Medicare to private insurance. That is why they are sometimes called "Medicare Replacement" Plans. Advantage Plans must cover at least what Medicare covers, so you don't lose areas of coverage, but the Plan sets the rules for how you receive your care, like having a network of doctors/hospitals, copays for visits and services, and treatment guidelines.

When you enroll in a Medicare Advantage Plan (MA/MAPD), you are still part of the Medicare program and must continue to pay your Part B premium, but the Plan provides all your Part A (hospital), Part B (medical) and Part D (prescription drug coverage) as one bundle. Almost all plans will include drug coverage and most plans include extra benefits like dental and vision coverage. Medicare Advantage Plans are county-based so your plan options are limited to the plans offered in your resident county.

How Medicare Advantage Plans Differ from Original Medicare

• You do not use your Medicare card. Instead, you will use your one Advantage Plan card at the hospital, doctor and pharmacy.
  
  
• All services (like PCP, specialist, x-ray, blood work, in-patient hospital admittance, physical and mental therapy, etc.) have a set copay (fixed dollar amount) or co-insurance (percentage) that you pay either up front at the appointment or are billed for afterwards.
  
  
• All plans have an annual maximum-out-of-pocket (MOOP) which puts a limit on your annual (January-December) financial responsibility for covered healthcare.
  
  
• You cannot use a Medicare Supplement/Medigap with a Medicare Advantage Plan. If you are enrolled in a MAPD, neither Original Medicare or your Supplement will pay and you must cancel your Supplement if you have one. You must proactively cancel your Supplement; it will not be cancelled automatically.
  
  
• There are usually extra benefits like vision (glasses), dental (cleaning and restorative), hearing (hearing aids), over the counter (OTC) allowance, gym memberships, and more.
  
  
• All Medicare Advantage plans have networks of doctors and hospitals. There are two types of networks: HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization).
  
  
  • With an HMO, you can only see doctors that are in-network. If you go out-of-network, you have no coverage and pay 100%, except for life threatening emergencies.
    
    
  • With a PPO, you can go to doctors in or out-of-network. If you go out-of-network, you pay a higher cost but still have coverage and a maximum out of pocket.

Part C Drug Coverage Explained

Most Medicare Advantage plans include drug coverage. If they do not include drug coverage, they are called MA-Only plans. The MA-Only plans are usually designed for veterans who get their drug coverage from the Veterans Administration (VA). Unless you have other credible drug coverage, you should have a full Medicare Advantage-Prescription Drug (MAPD).

Beginning 2025, after you meet your plan's drug deductible (if your plan has one), you will then pay a copay (or co-insurance) for your medicines at the pharmacy counter. If your out-of-pocket cost for covered prescriptions reaches $2,000, then you have met your drug maximum-out-of-pocket for the calendar year and your covered prescriptions are $0 for the rest of the year. Everything resets January 1st.

The Medicare Prescription Payment Plan (M3P) provides a way for Medicare beneficiaries to chop their prescription costs up into a monthly amount that is easier to manage and budget. When you opt-in to the Payment Plan, you don't pay for your prescriptions at the pharmacy counter anymore. Instead, your drug insurance carrier will spread the amount over the remainder of the calendar year and bill you monthly. For many with expensive medicines, the first part of the year brings very high up-front prescription bills. By using the M3P, you can avoid the requirement to pay it in such a short time frame. You can opt-in to the Program at any time by calling your insurance carrier.

Assistance for People with Limited Financial Resources

Individuals with income and assets below certain amounts set by the government can apply to Social Security for help with their out-of-pocket prescription costs. You can apply by calling Social Security at 1-800-772-1213 or online at www.ssa.gov. Low Income Subsidy/Extra Help reduces only your Advantage Plan premium and prescription costs; it does not reduce your medical costs. Imagine Insurance Advisors can help you apply. See our FAQ for more information.

Changing Your Plan and Plan Reviews

To make an appropriate recommendation, we request that you share with us a list of your doctors, prescriptions and a voluntary needs analysis (what areas of coverage are most important to you and if you have special healthcare needs). We use that information only to make plan recommendations and do not share/sell it with anyone. You can download and print these forms from our Contact Us page.

There are two periods during the year that you can change your Medicare Advantage Plan outside of Special Enrollment Periods. The first is the Annual Enrollment Period (AEP), which goes from October 15th to December 7th for a January 1st effective date. The other is the Medicare Advantage Open Enrollment Period (MA-OEP) that goes from January 1st to March 31st with the effective date being the 1st of the next month.

An agent at Imagine Insurance Advisors is happy to review your plan and work with you to find a plan in your area that is most suitable for your current needs or help you choose an Advantage Plan for the first time.

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