Medicare Advantage
What is Medicare Part C?
Medicare Advantage plans are also known as Part C. These plans include coverage for Part A, Part B, and usually Part D benefits. They are offered only by private insurance companies and typically have lower out-of-pocket costs than Original Medicare.
To qualify for a Medicare Advantage plan, you must be enrolled in Part A and Part B, and live in the service area. An example of a service area is Los Angeles or Santa Barbara County. In addition, the plan will always include a specific provider network.
Medicare Advantage plans must offer all Medicare Part A & Part B benefits (with limited exceptions) and some will offer additional coverage that is not offered by Original Medicare.
What is Medicare Part C?
Medicare Advantage plans are also known as Part C. These plans include coverage for Part A, Part B, and usually Part D benefits. They are offered only by private insurance companies and typically have lower out-of-pocket costs than Original Medicare.
To qualify for a Medicare Advantage plan, you must be enrolled in Part A and Part B, and live in the service area. An example of a service area is Los Angeles or Santa Barbara County. In addition, the plan will always include a specific provider network.
Medicare Advantage plans must offer all Medicare Part A & Part B benefits (with limited exceptions) and some will offer additional coverage that is not offered by Original Medicare.
Provider Networks
Because these policies are issued by private insurers, Medicare Advantage plans may offer several types of provider networks including:
Health Maintenance Organization (HMO)
- A Primary Care Physician referral is usually required.
- Most medical care will be provided by your chosen Medical Group or IPA.
- Out-of-network benefits are generally not covered unless it is Emergency or Urgent Care.
Preferred Provider Organization (PPO)
- A network of healthcare providers that have agreed to provide services to the plan members at a certain rate.
- You pay less for services from in-network providers.
- You may pay more for out-of-network providers outside of an emergency.
Private Fee-for-Service (PFFS)
- Some PFFS plans will allow their members to use any provider, while others will have a private network.
- The provider must accept Original Medicare and the plan’s payment terms and conditions outside of an emergency.
Special Needs Plans
Beyond the provider network, Medicare Advantage plans may also be designed to target their care to certain populations. This limits enrollment to individuals with special needs such as:
Chronic Special Needs Plan (C-SNP): A disabling chronic condition such as Diabetes, Chronic Heart Failure, or COPD
- Dual Eligible (D-SNP): Medicare and Medicaid eligible
- Institutional (I-SNP): Living in an institution (nursing home) or requiring nursing level care at home