01HMO
Health Maintenance Organization
You use doctors and hospitals in the plan network, and you usually pick a primary care doctor who refers you to specialists. Care outside the network is generally covered only in an emergency.
Part C
Medicare Advantage, start to finish.
One plan from a private insurer that delivers your Part A and Part B coverage, usually adds prescription drugs, and puts a ceiling on what a bad year can cost you.
How it works
What changes when you join a Part C plan.
You are still on Medicare. What changes is who administers the coverage, how you access care, and what your worst-case year looks like.
- You stay enrolled in Medicare and keep paying your Part B premium. The Advantage plan is how you receive that coverage, not a replacement for being on Medicare.
- The plan must cover everything Original Medicare covers, apart from hospice care, which Part A continues to pay for directly.
- Every Medicare Advantage plan has an annual limit on what you pay out of pocket for covered Part A and Part B services. Original Medicare on its own has no such limit.
- Most Advantage plans include Part D drug coverage. Those are called MA-PD plans, and joining one means you do not buy a separate drug plan.
- Many plans include extra benefits Original Medicare does not cover, such as routine dental, vision, hearing, or fitness. What is included varies widely by plan and county.
- You cannot use a Medigap policy with a Medicare Advantage plan, and a Medigap policy will not pay your Advantage plan cost sharing.
Plan types
The letters on the plan name tell you the network rules.
Most people are choosing between an HMO and a PPO. The other types exist for narrower situations.
02PPO
Preferred Provider Organization
You can go outside the network, though you pay more when you do, and referrals are usually not required. The trade for that flexibility is often a higher premium or higher cost sharing.
03SNP
Special Needs Plan
Built for a specific group: people with both Medicare and Medicaid, people living in an institution, or people with a qualifying chronic condition. Benefits and drug lists are tailored to that group.
04Other types
PFFS and MSA plans
Less common structures. A Private Fee-for-Service plan sets its own payment terms with providers who agree to accept them. A Medical Savings Account plan pairs a high deductible with a deposited savings account.
Before you enroll
Six questions worth answering first.
A plan that looks identical on paper to a neighbor plan can behave very differently once you use it, because the differences live in the network, the drug list, and the copay schedule. Work through the checklist below with your own doctors and prescriptions in hand rather than comparing premiums alone.
- Are your doctors, specialists, and preferred hospital in the plan network this year, and confirmed by the provider office rather than only by the directory?
- Are your prescriptions on the plan drug list, at what tier, and does the plan require prior authorization or step therapy for any of them?
- What is the annual out-of-pocket maximum, and what are the copays for the services you actually use, such as specialist visits, imaging, and hospital stays?
- Does the plan cover you when you travel outside its service area, and what happens if you spend part of the year in another state?
- If extra dental, vision, or hearing benefits matter to you, what is the yearly allowance and which providers accept it?
- What changed in the Annual Notice of Change your current plan sent you this fall?
Your windows
When you can join, switch, or leave.
- Annual Enrollment Period, changes start January 1
- Oct 15 to Dec 7
- Medicare Advantage Open Enrollment, one change
- Jan 1 to Mar 31
- Initial Enrollment Period around your 65th birthday
- 7 months
- stays covered by Part A, even on an Advantage plan
- Hospice
Good to know
Questions people ask about Advantage plans.
Do I still pay the Part B premium on an Advantage plan?
Yes. You keep paying your Part B premium to Medicare, and you pay any premium the Advantage plan charges on top of it. Some Advantage plans have a $0 monthly plan premium, which is a common source of confusion: the plan premium and the Part B premium are two separate things.
When can I join, switch, or leave a Medicare Advantage plan?
During your Initial Enrollment Period when you first come onto Medicare, during the Annual Enrollment Period from October 15 through December 7 with changes effective January 1, and during Medicare Advantage Open Enrollment from January 1 through March 31 if you are already in an Advantage plan. That spring window lets you switch to a different Advantage plan or return to Original Medicare with a drug plan, once. Special Enrollment Periods can also open after events such as a move or a loss of other coverage.
What happens if I go outside the network?
It depends on the plan type. An HMO generally covers out-of-network care only for emergencies, urgent care, and out-of-area dialysis. A PPO covers out-of-network care but at a higher share of the cost. Emergency and urgently needed care is covered under any Advantage plan, wherever you are in the country.
Can a plan drop my doctor or change my drugs mid-year?
Provider networks and drug lists can change during the year, and plans have to give notice when they do. Bigger changes to premiums, copays, and covered benefits happen at the plan year boundary and are described in the Annual Notice of Change you receive in the fall.
Can I switch back to Original Medicare later?
Yes, during the Annual Enrollment Period or the Medicare Advantage Open Enrollment Period. One caution: your right to buy a Medigap policy without medical underwriting is limited to specific windows and situations. If you leave Advantage for Original Medicare years later, an insurer may be allowed to consider your health when pricing or approving a Medigap policy, depending on your state and circumstances.
Part C
See the Medicare Advantage plans offered where you live.
Enter your ZIP code to compare networks, drug coverage, and out-of-pocket limits side by side.