How Does Medicare Advantage Work? | Medicare Health Plans

Medicare Health Plans is an independent review site. However, we may earn money when you click on links on our site. Read more about How We Make Money

How Does Medicare Advantage Work?

Medicare Advantage (MA), also called Part C,  is a way to get Part A and Part B coverage from a private health insurance company. To get started, review and pick a plan, then get enrolled.

This page will tell you how to expect an MA Plan to work, from enrollment to getting care and paying out-of-pocket costs.

Important Enrollment Dates

The first stage is enrollment, whether you’re newly eligible or have been a beneficiary for a while. You have the choice to enroll in an MA plan during these certain periods:

  • Initial Enrollment. This is period applies if you have just become eligible for Part A and Part B due to age or disability (initial enrollment). You can sign up for Part A and B or enroll in an MA plan by purchasing one on the open market.
  • Open Enrollment. This period occurs every year from October 15 to December 7. During this time, you can switch from plan to plan. If you already have MA, you can also choose a different Part C Plan from your current insurance company or another company altogether.

If you want to enroll during one of these enrollment periods, you’ll need to review the plans that are available to you on the open market. You can visit insurance company websites, use medicare.gov’s plan finder tool,or let us help you compare plans in your area and find one that may save you money.

If you’re wondering what an MA plan covers and how it differs from Part A and B, read Why Choose Advantage? Once you have reviewed the plans available to you and decide on the right one for your needs, you’ll speak to a licensed agent or the insurance company to get a quote.

If you accept the terms and cost of the plan, you’ll work with the agent and insurance company to get enrolled. Sometime before January 1, you should receive your plan documents materials, including:

  • MA ID Card (this is separate from your government-issued card)
  • Plan information, showing covered benefits and services
  • Prescription drug information, if included in your plan
  • Additional forms and resources such as dental, wellness, or fitness programs

When you receive these materials, review them to ensure that you understand what is covered by your plan and how the insurance company requires you to get care.

Getting Care

Once enrolled, you can get health care services using the plan. If you get sick, have an accident, or need preventive care, you’ll need to make sure you see a doctor that accepts your plan.

First, check your plan materials to see if you are required to use the plan’s network to receive care. If you have a Health Maintenance Organization (HMO) plan, you’re required to stay within in the network. If you have a Preferred Provider Organization (PPO) plan, you may use other doctors, but you’ll likely pay more out of pocket.

Check with the insurance company to see if it can direct you to a doctor, specialist, or facility that can serve your health care needs. The company may even help you make the appointment. Bring your MA ID card with you to the appointment. You may also need to bring payment with you, depending on the type of  plan you chose.

Paying for Costs

The cost of plans consists of several different buckets, all of which depend on the type of plan. These are the five major buckets:

  • Part B premium
  • MA premium
  • Deductibles
  • Copays and coinsurance
  • Additional costs

The first bucket is the Part B premium, which nearly all beneficiaries pay, regardless of whether they choose Part A and B or Part C. The basic Part B premium for 2016 is $121.80, but this amount may change depending on your income. It is deducted from your Social Security benefits. If you don’t receive those benefits, you’ll receive a bill.

Some plans carry their own premiums, which you will pay directly to the insurance company. Most companies allow you to set up automatic withdrawals from a bank account to pay your premium.

A deductible is an amount that you are responsible to pay before your insurance benefits “kick in.” For example, if you have a plan with a $50 deductible, you’ll pay up to $50 for most health care services. Once you’ve met the $50, the plan will start to pay for health care according to your plan guidelines.

Your plan may also include copays or coinsurance amounts. These are costs that you pay for certain services like doctor visits or hospital stays. A copay is a set dollar amount—such as $25—and coinsurance is a percentage of charges—like 20%.

There may be additional costs associated with your plan. These could be for dental or fitness benefits. In addition, if you don’t follow the plan’s guidelines, you may be charged for any charges that the plan won’t cover.

Now that you know how it works, you may be ready for the next step of getting enrolled.  If you need to learn the basics on the differences between Part A and B, Part C, and Medigap, first read the FAQ: Which Plan Should I Choose?

This site is a U.S. Consumer site. You can learn more about our site and privacy policy here.