How Does Medicare Advantage Work (Plan C)

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Medicare Part C also is known as a Medicare advantage plan or MA plans are healthcare plans offered by private health insurance companies approved by Medicare to provide coverage for Medicare Part A and Part B, as well as additional coverage for vision, dental, and hearing care. It is the private health insurance alternative to the federally run original Medicare.

 Medicare Advantage plans is an alternative to Original Medicare that provides all of your Part A and Part B benefits and goes a step further to offer other additional benefits like hearing and vision coverage


  • Medicare Part C is an ‘all in one alternative to original Medicare which covers Part A, Part B, and usually Part D
  • Medicare Part C may have lower out-of-pocket costs in comparison with Original Medicare
  • You can mostly use doctors and healthcare providers who are in the plan’s network.
  • What you pay in a Medicare Advantage plan depends on several factors. In most cases, beneficiaries would need to use a doctor and other health service providers outside the plans network and service area for the lowest costs.
  • Medicare Advantage plans only offer coverage when you are in your plans service area. Some plans won’t cover services from providers outside the plans network and service area.
  • Most Medicare Advantage plans provide additional benefits like hearing, dental and vision coverage.


Medicare Part C combines coverage for hospital care, doctor visits, and other medical services all in one plan. Plans are required to provide all of the benefits offered by Medicare Parts A and B (except for Hospice care which of course is provided by Part A). Most plans also offer coverage for prescription drugs you take home.

The exact prescription drugs that are covered are listed in the plan’s formulary. Formularies may vary from plan to plan. Generally, services covered by Medicare Part C (under Medicare Part A and Part B) include:

  • Inpatient hospital care
  • Skilled nursing facility care
  • Lab tests
  • Surgery
  • Some home healthcare
  • Doctor visits
  • Durable medical equipment like wheelchairs and walkers
  • Preventive services, such as vaccines
  • Emergency and urgent care

The Centres for Medicine and Medicaid services, which sets the rules for Medicare, has in recent years allowed Medicare Advantage plans to cover extra services such as wheelchair ramps and shower grips for your home, meal delivery and transportation to and from doctor’s offices.

Other extra benefits covered by Medicare Part C include:

  • Routine dental care, including cleanings, X-rays and dentures
  • Routine vision care including contacts and eye glasses
  • Fitness benefits including exercise classes.

Subsequently, not all Medicare Part C plans cover extra benefits in the same way. Some Medicare Part C plans, for instance, may only cover MEDICARE-COVERED DENTAL BENEFITS which means it only covers dental care in the case relating to a disease or accident that affected the jaw. However, if your Medicare Part C covers dental care more extensively, then you’ll be required to subscribe to a higher premium for that service.

Beneficiaries who are denied coverage for something they need are advised to file an appeal. You can appeal to a health care service, supply, item, or prescription drug that you think you should get. You can also file an appeal to pay less the amount you were required to pay.


Eligibility for Medicare Part C is dependent on whether you qualify for Part C benefits. To qualify for Medicare Part C, the following requirements must be met:

  • You must have Medicare Part A and Part B
  • You must live in a Medicare Advantage plan service area
  • You must not have end-stage renal disease (ESRD)

To qualify for Medicare Part A and Part B, you must meet the following requirements:

  • You must be 65 years or older
  • You must have disability and must have been receiving social security benefits for 2 years
  • You must have End-Stage-Renal-Disease (ESRD)
  • You must have Lou Gehrig’s disease (ALS)

Beneficiaries with ESRD can, however, qualify for Medicare Part C Special Needs Plan.


  • Out-of-pocket costs may vary depending on your subscribed plan. Plans may have lower out-of-pocket costs for certain services.
  • Medicare Advantage plans have a yearly limit on what you pay out of pocket for services covered by Medicare Part A and Part B. once a subscriber reaches that limit, Part A and Part B services will still be covered for the remainder of the year.
  • Subscribers may pay the plan’s premium in addition to the monthly Part B premium (Medical insurance) – most plans include Medicare drug coverage. Plans may have a $0 premium or may help beneficiaries pay all or part of their Part B premium.

Out-of-pocket costs in a Medicare Advantage plan could depend largely on:

  • The type of health services a beneficiary needs and how often it can be received
  • If the plan charges a monthly premium. Some plans have no premiums
  • If the plan has a yearly deductible or any additional deductibles.
  • If the plan pays its beneficiaries their monthly Medicare Part B premium. Some plans pay some part or all the Part B premium.
  • How much beneficiaries pay per visit or service rendered (coinsurance or copayment). For instance, a plan may charge a copayment of about $10 to $20 dollars for every doctor’s visit. These amounts differ from those in Original Medicare.
  • The plans yearly limit on out-of-pocket costs for medical services
  • Whether you see a doctor that accepts your assignment if; you go out-of-network or you’re in a PPO, PFFS, or MSA plan.


The most common types of Medicare Advantage plan available include:     

  • Health Maintenance Organisations (HMO) Plans
  • Preferred Provider Organisation (PPO) Plans
  • Point of Service (POS) Plans
  • Special Needs Plan (SNP)
  • Private Fee for Service (PFFS) Plans
  • Medical Savings Account (MSA) Plan
  • The Health Maintenance Organization (HMO) Plans: this plan uses a network primary care provider to help coordinate care. HMO plans mostly only pay for providers in the plan’s network except for emergency care, out-of-area urgent care, and out-of-area dialysis.
  • Point of Service Plans (POS): Point of service plans have the benefits of an HMO, but with more flexible provider choice. In this type of plan, costs are generally lower for using in-network.
  • Preferred Provider Organization (PPO) Plan: This plan is offered by a private insurance company and it covers providers both in and out of the network, unlike the HMO plan. The PPO plan pays a portion of the cost of using an out-of-network provider. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network but pay more if they are outside the plan’s network.
  • Special Needs Plans (SNPs): Special needs plans have benefits that cover special health care or financial needs. Under this plan, membership is limited to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices. Drug formularies to best meet the specific needs of groups. This plan is quite distinct from the other plans as it pays particular attention to people with specific health care needs.
  • Private Fee-for-Service (PFFS) Plans: PFFS plans may or may not have a provider network, but usually cover any provider who accepts Medicare. The plan determines how much it will pay doctors, other health care providers, and hospitals and how much you should pay when you get a car. The plan may not include prescription drugs, so you may have to enroll in a stand-alone part D plan separately.
  • Medical Savings Account Plan: This plan combines a high-deductible health plan with a special savings account. Medicare deposits funds that are withdrawn tax-free to pay for qualified health care services, so you can afford to see any provider you want. Like PFFS plans, MSA plans don’t cover for prescription drugs, but you can enroll in a separate standalone part D plan.

It is important to note that not all these plans cover the same extra benefits offered in Part C, so beneficiaries should endeavor to read the plans specifications properly before choosing a plan.


Most Medicare Advantage plans provide prescription drug coverage for beneficiaries. For those that do not offer prescription drug coverage, you can buy it through a private health insurer.

 This generally has premiums and other out-of-pocket costs, either flat copays for each medication or a percentage of the prescription costs. Some may have an annual deductible. If the total drug cost (the amount paid by you and your Part D insurance plan) reaches $4,020 in 2020, the beneficiary will be responsible for 25% of the price of the rest of the prescription drugs purchased for the year.

Subsequently, if the drug cost continues to mount, the beneficiary may then reach a point of qualifying for catastrophic coverage. For 2020, once payment of $6350 is made for medicines (just what you paid, excluding what your Part D insurance plan paid), you’ll be responsible for 5% of the cost for each of your drugs.

It is important to make proper inquiries before deciding which plan you’ll love to be enrolled in. This will help you decide if the plan you’re considering has your preferred medicines on its covered list (Formulary). Those lists are modified yearly, so it’s necessary to recheck your plan annually when its time for open enrollment.

The next open enrollment will kick start from October 15th – December 7th 2020, and any changes made during this period will be effective in January 2021.