Medicare Advantage Part C

What is Medicare Advantage?


Medicare Advantage plans are alternatives to Original Medicare. By law, they must cover everything Part A (hospital) and Part B (medical) cover, and many plans include prescription drug coverage (Part D) plus extras like dental, vision, and hearing. You still keep Medicare—you just get your benefits through the plan’s network and rules.

Requirement Details
Medicare entitlement You must be enrolled in BOTH Part A and Part B before your Medicare Advantage (MA/Part C) coverage can start.
Age or qualifying condition Typically age 65+. Under 65 may qualify after 24 months of SSDI or with ALS/ESRD (MA plans accept ESRD).
Residence You must live in the plan’s service area (county/ZIP). Long stays outside the area (usually >6 months) can lead to disenrollment.
Enrollment window Enroll during your Initial Enrollment Period (IEP/ICEP), Annual Enrollment (Oct 15–Dec 7), MA Open Enrollment (Jan 1–Mar 31), or a Special Enrollment Period (SEP) if you qualify.
General Medicare eligibility Must be a U.S. citizen or lawful permanent resident (generally 5+ continuous years) and eligible for Medicare.


What Medicare Advantage Plans Cover

Required by law

  • All Part A and Part B services
  • Emergency and urgent care (U.S.; some plans add limited worldwide emergency)

Paid by Original Medicare even if you’re in MA

  • Hospice (MA plans may add supplemental services around hospice)

Common add-ons (vary by plan)

  • Part D drug coverage (MA-PD)
  • Dental, vision, hearing benefits
  • Fitness/wellness programs (e.g., gym)
  • Transportation, OTC allowances, meals, in-home support, telehealth




Plan Types (how they differ)

  • HMO – Lowest costs, network required, referrals often needed; emergencies covered anywhere.
  • PPO – Can go out-of-network at higher cost; no referrals.
  • PFFS – No network in some cases; provider must agree to plan’s payment terms each visit.
  • SNPs – For special populations (Chronic/CSNP, Dual-eligible/DSNP, Institutional/ISNP).
  • MSA – High deductible + medical savings account; no drug coverage (add stand-alone Part D).



Enrollment Periods (the windows)


  • Initial Enrollment Period / ICEP – 7-month window around your 65th birthday (3 months before, birth month, 3 months after).
  • Annual Enrollment Period (AEP) – Oct 15–Dec 7: join, switch, or drop an MA or Part D plan; coverage starts Jan 1.
  • Medicare Advantage Open Enrollment (MA-OEP) – Jan 1–Mar 31: already in MA? Switch to a different MA plan or return to Original Medicare and join Part D.
  • General Enrollment Period (GEP) – Jan 1–Mar 31 to sign up for Part A/B if you missed it; once A/B is active, you can pick an MA plan.
  • Special Enrollment Periods (SEPs) – Moving, losing other coverage, plan termination, Medicaid/Extra Help eligibility, 5-Star SEP (switch once between Dec 8–Nov 30 if a 5-star plan is available).





What It Costs (and why it varies)

  • Part B premium – You pay this even if your MA plan is $0. Amounts change each year and can vary with income.
  • Plan premium – Many plans are $0, some charge a monthly amount.
  • Medical cost-sharing – Copays/coinsurance for visits, hospital, imaging, etc. (often with prior authorization rules).
  • MOOP (Maximum Out-of-Pocket) – Annual cap for Part A/B spending within the plan; after you hit it, the plan covers approved Part A/B services at 100% for the rest of the year.
  • Drug costs (if MA-PD) – Deductible + tiered copays/coinsurance through the coverage stages.
  • Out-of-network costs – PPOs allow it at higher cost; HMOs typically don’t cover out of networks services (except emergency/urgent).
  • Extras – Dental/vision/hearing allowances, OTC cards, transportation, etc., each with their own rules and caps.



Note: Premiums, MOOP limits, and drug rules change annually.


Pros & Watch-outs

Pros

  • One card; often $0 premium options
  • MOOP protection (Original Medicare doesn’t have a built-in cap)
  • Extras like dental/vision/hearing, fitness, OTC, transportation
  • Care coordination and prior authorization can limit unnecessary costs

Watch-outs

  • Networks (especially HMOs) and referrals
  • Prior authorization for many services
  • Coverage rules can differ by county
  • Changing plans can impact drug coverage and provider access



How to Choose (3-step quick guide)

  1. List your essentials: doctors/hospitals, drugs (names + dosages), preferred pharmacies, and any must-have extras.
  2. Compare: check premiums, MOOP, copays, drug formularies, networks, and star ratings.
  3. Stress-test costs: run your common care scenarios (PCP/specialist visits, labs, hospital) and worst-case: MOOP.



FAQ (short answers for common objections)

  • Do I still pay my Part B premium? Yes—regardless of plan premium.
  • Can I have Medigap with MA? No—Medigap works only with Original Medicare.
  • Travel? Emergencies covered; routine care depends on network and plan type.
  • Dialysis/ESRD? You can join MA plans.
  • Is Hospice covered? Generally paid by Original Medicare even if you’re in MA.