What is a Medicare Advantage plan?
(Commonly Referred to as Medicare Part C)

Medicare Advantage also known as Medicare Part C is an alternative way to receive your Medicare benefits. Instead of getting your Medicare coverage through the federal government (Original Medicare), you get it through a private insurance company that is approved and contracted by Medicare.

You enroll in a Medicare Advantage plan through a private insurance company. That plan becomes your primary insurer instead of the federal Medicare program. The insurance company provides you with a network of doctors, specialists, hospitals, and possibly pharmacies to use.

• Monthly premium: Some plans cost $0/month (though you must still pay your Part B premium, which is usually taken from your Social Security check)

• Copays/coinsurance:

  Pay-per-service (e.g., $10 to see your PCP, $40 to see a specialist)

• Out-of-pocket maximum: Once you hit this limit, the plan pays 100% of covered costs for the rest of the year

What is Part C?

How Does It Work?

What Will It Cost?

Pro's & Con's of Part C

Pro's

Con's

All-in-one coverage (medical, hospital, and often prescription + dental/vision)

Lower or $0 monthly premiums

Extra benefits not covered by Original Medicare

Annual out-of-pocket maximum for medical expenses

Coordinated care through provider networks

Provider networks may be limited to your local area

Referrals may be required

You may need prior authorizations for certain services

Plan rules and benefits can change every year

Out-of-network care can be expensive or not covered, depending on the plan type

Medicare Acronyms To Remember

PCP (Primary Care Provider)
The main doctor or provider who manages a beneficiary’s overall health and gives referrals for specialists or services in certain plan types (like HMO's).

HMO (Health Maintenance Organization)
A Medicare Advantage plan type where you must use in-network providers and get referrals from your PCP to see specialists (except emergencies).

PPO (Preferred Provider Organization)
A Medicare Advantage plan with more flexibility—allows visits to out-of-network providers (usually at a higher cost) and doesn't require referrals.

POS (Point of Service)
A type of HMO plan that allows some out-of-network services, often with a higher copay or coinsurance. Requires PCP and referrals, but with more flexibility than a standard HMO.

PFFS (Private Fee-for-Service)
A Medicare Advantage plan that determines how much it will pay doctors and hospitals and how much you must pay. Some PFFS plans have networks, others don’t.

SNP (Special Needs Plan)
A Medicare Advantage plan designed for people with specific diseases, dual eligibility (Medicare & Medicaid), or those in institutions. Provides tailored care.

C-SNP (Chronic Condition Special Needs Plan)
A type of SNP for people with certain chronic conditions (e.g., diabetes, COPD, heart disease). Care is coordinated around those specific health needs.

D-SNP (Dual Eligible Special Needs Plan)
A type of SNP for individuals who qualify for both Medicare and Medicaid. Offers coordinated care and extra benefits for low-income beneficiaries.

I-SNP (Institutional Special Needs Plan)
A type of SNP for individuals living in nursing homes or who need nursing care at home for 90 days or longer.

MA (Medicare Advantage)
Also known as Part C; an alternative to Original Medicare that bundles Part A, Part B, and usually Part D into one private plan.

MAPD (Medicare Advantage Prescription Drug Plan)
A Medicare Advantage plan that includes prescription drug coverage (Part D).

MSA (Medical Savings Account)
A high-deductible Medicare Advantage plan combined with a savings account you can use for medical expenses.

Finding the right plan for your needs

• There’s no one-size-fits-all. Every Medicare Advantage plan has different premiums, networks, and benefits—what works for someone else may not work for you.

• Benefit trade-offs are common. You might get great dental but limited hearing aid coverage, or strong vision but weaker over-the-counter benefits.

• Lower copays usually mean fewer extras. Plans with lower out-of-pocket costs tend to offer less robust ancillary benefits like dental, vision, or fitness perks.

• Network types matter.

  • HMO = lower cost, smaller local network, referrals needed.

  • PPO = larger network, more flexibility, higher costs.

  • POS/PFFS = more options, but less predictability.

• Your needs change—your plan should too. A new health condition, medication, or move can make your current plan less ideal.

• That’s why having a broker matters.

  • They shop nearly every carrier in your area.

  • Help you compare real differences in benefits and costs.

  • Offer free, unbiased guidance year after year.

• No extra cost to you. Brokers are paid by the carriers, so their help costs you nothing—but can save you a lot.

Medicare Part C

Medicare Advantage (Continued)

Medicare Advantage (Part C) plans are offered by private insurance companies that are approved by Medicare.

These plans combine the coverage of Medicare Part A and Part B into a single plan and are required to provide at least the same level of coverage as Original Medicare.

Most Medicare Advantage plans also include additional benefits that Original Medicare typically does not cover.

These often include:

• Dental services

• Vision care

• Hearing exams and hearing aids

• Prescription drug coverage

• Fitness programs

• Transportation or wellness benefits

Many Medicare Advantage plans are available with $0 monthly premiums, although members must still continue paying their Part B premium.

Costs such as co-pays and coinsurance vary depending on the specific plan.

It is also important to understand that Medicare Advantage plans vary by county, meaning the plans available in one area may be different from those offered in another.

Chronic Condition Special Needs Plans (C-SNPs)

Certain Medicare Advantage plans are specifically designed for individuals with chronic health conditions.

These are known as Chronic Condition Special Needs Plans.

These plans are built to better manage specific health conditions and often offer:

• Lower copays for condition-related care

• Coordinated care programs

• Additional benefits tailored to those health needs

• Most plans offer an allocated allowance for healthy foods.

Qualifying conditions may include things such as diabetes, cardiovascular disorders, kidney disorders or chronic heart conditions.

Medicaid and How It Differs From Medicare

While Medicare is a federal health insurance program, Medicaid is a state and federally funded program designed to assist individuals with limited income and financial resources.

Medicaid programs vary by state, meaning eligibility rules and benefits can differ depending on where a person lives.

People may qualify for Medicaid based on factors such as:

• Income level

• Household size

• Disability status

• Long-term care needs

Some individuals qualify for both Medicare and Medicaid. These individuals are commonly referred to as “dual eligible.”

Medicare and Medicaid Together

When someone has both Medicare and Medicaid, they may receive significant additional support with healthcare costs.

Medicaid can help cover expenses such as:

• Medicare premiums

• Deductibles

• Copayments

• Certain long-term care services

Individuals who qualify for both programs may also be eligible for special Medicare Advantage plans designed specifically for dual eligible beneficiaries.

These plans often include additional benefits such as:

• Enhanced dental coverage

• Over-the-counter benefit allowances

• Food or utility assistance programs (depending on plan availability)

• Transportation services

• Care coordination services

Because Medicaid eligibility and benefits vary by state, the exact coverage and assistance available can differ from one location to another.

When Can You Enroll?

(In a Medicare Advantage Plan)

Initial Enrollment Period (IEP)

• When: 7-month window around 65th birthday
  Who: New to Medicare (age 65 or disabled)
  What You Can Do:

• Enroll in Parts A & B

• Join a Medicare Advantage (Part C) plan

• Join a Part D drug plan

• Buy a Medigap (supplement) policy
  

Annual Enrollment Period (AEP)

• When: October 15 – December 7
  Who: All Medicare beneficiaries

• 
  What You Can Do:

• Switch from Original Medicare ↔ Medicare Advantage

• Switch Advantage plans

• Join, drop, or switch a Part D plaN

• Changes Take Effect: January 1
  

Medicare Advantage Open Enrollment Period (MA OEP)

• When: January 1 – March 31
  Who: People currently enrolled in a Medicare Advantage plan

• 
  What You Can Do:

• Switch Advantage plans

• Drop Advantage and return to Original Medicare (and join Part D)

• Note: Cannot switch from Original Medicare to Advantage during this period.

Medigap (Supplement) Enrollment Period

• When: 6 months after you’re 65 and enrolled in Part B
  Who: Those wanting Medigap (to pair with Original Medicare)
  What You Can Do:

• Buy any Medigap plan with no health questions asked

• Note: After this period, underwriting may apply.

Special Enrollment Periods (SEPs)

• When: Varies by life event
  Who: People with qualifying circumstances (e.g., moved, lost coverage, Medicaid changes)
  What You Can Do:

• Enroll in, switch, or drop Part A, B, C, or D plans

• Avoid penalties with valid SEP reason

• Examples: Moved, lost employer coverage, gained/lost Medicaid, plan termination

Types of Plan Networks

HMO (Health Maintenance Organization)

What it means:
An HMO plan requires members to use a specific network of doctors and hospitals. Care must be coordinated through a Primary Care Physician (PCP), and referrals are needed to see most specialists.

Key features:

PCP required

Referrals needed for specialists

No coverage outside the network (except in emergencies or urgent care)

Usually has lower monthly premiums and out-of-pocket costs

Who it's best for:
Someone who wants lower costs and is okay with a more limited provider network and going through a PCP

PPO (Preferred Provider Organization)

What it means:
A PPO plan offers more flexibility in choosing healthcare providers. Members can see any doctor or specialist, but they’ll pay less when staying in-network.

Key features:

No PCP required

No referrals needed for specialists

Out-of-network coverage available, but more expensive

Usually higher premiums than HMO plans

Who it's best for:
People who want freedom to choose doctors without referrals, even if it means paying more.

POS (Point of Service)

What it means:
A POS plan combines elements of HMO and PPO. You choose a PCP and need referrals for specialists, but you have limited out-of-network coverage if you're willing to pay more.

Key features:

PCP required

Referrals needed

Out-of-network care is partially covered, but higher cost

Balances cost savings of HMO with flexibility of PPO

Who it's best for:
Those who want coordinated care but also want some flexibility to go out of network if necessary.

PFFS (Private Fee-for-Service)

What it means:
A PFFS plan lets members see any Medicare-approved provider who agrees to accept the plan’s payment terms. No network restrictions, but providers must accept the plan on a case-by-case basis.

Key features:

No network — freedom to choose providers

No PCP or referrals required

Doctors/hospitals can refuse to accept the plan, even if they previously accepted it

Costs and coverage can vary widely

Who it's best for:
Someone who wants maximum freedom, but is okay with doing extra legwork to find providers who accept the plan.

Medicare Advantage Vs. Medicare Supplement

What Is Medicare Advantage (Part C)?

• Offered by private insurers as an all-in-one alternative to Original Medicare

• Includes Part A, B, and usually Part D (prescription drugs)

• May include dental, vision, hearing, OTC, fitness, and more

• You still pay your Part B premium

• Low or $0 monthly plan premiums

• Uses provider networks (HMO or PPO)

• Copays/coinsurance apply when you use services

• Annual maximum out-of-pocket protection

• Benefits and costs can change each year

What Is a Medicare Supplement (Commonly Refered to as Medigap)?

• Works alongside Original Medicare (Parts A & B)

• Covers some or all deductibles, copays, and coinsurance

• No extra benefits (dental, vision, hearing, prescriptions)

• Requires separate Part D drug plan

• Higher monthly premiums, but fewer surprise costs

• No network restrictions—see any doctor who accepts Medicare

• Coverage is stable year after year

• May require medical underwriting if enrolling late

Why Understanding Medicare Matters

Medicare provides an essential foundation for healthcare coverage in retirement, but navigating the program can often feel overwhelming due to the number of options available.

Understanding the differences between Original Medicare, Medicare Advantage plans, and Medicare Supplements can help individuals choose coverage that best fits their healthcare needs, financial situation, and lifestyle.

Because plan availability, networks, and benefits can vary by location, it is often helpful to review available options with a licensed professional who can explain the details and help individuals make informed decisions about their coverage