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Medicare Advantage Insurance

What is Medicare Part C or Medicare Advantage?

Medicare Advantage plans are sometimes referred to as Medicare Part C. They are Medicare-approved private health insurance plans, for individuals enrolled in Original Medicare Parts A and B. When you join a Medicare Advantage plan, you are still in the Medicare program and must continue paying your Part B premium.

Medicare Advantage plans must, at a minimum, provide all of what Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) covers. They generally offer additional benefits, such as vision, dental, and hearing, some include other supplemental benefits, and many include prescription drug coverage. These plans often have networks, which mean you may have to see certain doctors and go to certain hospitals in the plan’s network to get care.

Medicare Advantage plans may potentially save you money because out-of-pocket costs in these can be lower than with Original Medicare. Also, Medicare Advantage plans are required to limit the out of pocket costs and have built into the plan, a maximum out of pocket limit, which is something that original Medicare Parts A and B does not have.

Most Medicare Advantage plans usually cover additional benefits like Dental, Vision, Hearing, some include other supplemental benefit, and Medicare Part D Prescription Drug benefits. Medicare Advantage plans take away the unknown 20% on most coverage’s and instead give you specific co pays and deductibles for each service performed. These coverage’s typically reduce the potential out of pocket expenses a member might have for services provided by a provider. In general, the costs are less than a person would pay with original Medicare.

Pricing will vary by plan provider, so it is worthwhile to compare all plans in your area. Your costs will vary by the services you use and the type of plan you decide to enroll in. Each Medicare Advantage plan can charge different monthly premium amounts and have different pricing for out of out-of-pocket costs. These plans can administer different rules for how you get services (like whether you need a referral to see a specialist or can use only doctors, facilities, or suppliers in the network).

Plan options can include:

  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Private Fee-for-Service (PFFS)
  • Special Needs Plans (SNPs)
  • HMO Point-of-Service (HMOPOS)
  • Medical Savings Account (MSA)

HMO VS PPO Plans

Most Medicare Advantage plans fall into two categories called either an HMO (Health Maintenance Organization) plan or a PPO (Preferred Provider Organization) plan.

An HMO policy typically requires an individual to stay within their network of doctors. Usually, the cost of the HMO plan is less, as the plans have a contract with the providers that require them to charge the insurance company a specific amount for each covered service. This helps keep the costs down for the plans, which in turn gives the customer better pricing for the covered services in the form of premiums, co pays, and deductibles. HMO’s are a great option, as long as the providers you desire to see are within the network, or the network has the providers you would like to see. Plans are required by Medicare to have a minimum amount of providers of every specialty and service, to cover the membership requirements of their members. It is important when choosing a Medicare Advantage of any type to ensure that the doctors you desire to see are within their network of providers.

A PPO works a little differently. Typically, a PPO like an HMO has a network of providers. In general, if one stays within the network, the cost of the service will be lower, as, like the HMO, the providers have a contract with the PPO plan to provide covered services at a specific price determined in their contract for each covered service. If you join a PPO network, you can go to these providers at the prices set within the plan’s summary of coverage booklet showing your potential co pays and deductibles. With the PPO plan, unlike the HMO, you do have the option of going outside of the provider network, usually at a higher cost sharing to you. These terms are also provided in the summary of coverage booklet provided by your plan.

You can generally join if:

  • You live in the service area of the plan you want to join.
  • You have Original Medicare, Parts A and B, coverage.
  • You do not have end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant); however, there are a few exceptions.

If a person receives Medicare during the year, for reasons like they are turning 65, they are eligible for disability Medicare, or they are leaving a group health plan through a current employer, they will have an enrollment period in which they will have the opportunity to enroll in one of these plans.

Choose your Plan Carefully

Outside of when you first become eligible to enroll, and other personal circumstances that may qualify you for a Special Election Period, you are only able to change plans once a year during the Annual Election Period. The Annual Election Period lasts from October 15th through December 7th of each year. If you apply for a Medicare Advantage during the open enrollment period, the plan will begin January 1 and will provide coverage for the whole year until December 31.

In 2020, a new Medicare Advantage Open Enrollment Period will run from January 1 – March 31 every year. If you are enrolled in a Medicare Advantage plan, you will have a one-time opportunity to:

  • Drop a Medicare Advantage Plan (Part C) and return to Original Medicare
  • Elect to change from one Medicare Advantage plan to a different one
  • Change from Original Medicare to a Medicare Advantage plan
  • Elect to change from one Part D prescription drug plan to another
  • Cancel your current Part D plan
  • Pick up a Part D plan if you currently do not have one

Most Medicare Advantage plans include prescription drug coverage already. Usually, you cannot enroll in a stand-alone Medicare Prescription Drug plan if you already have a Medicare Advantage plan, but there are some situations where you can. Call your Medicare Advantage plan if you have questions.

There is also a Medicare Advantage Disenrollment Period, which runs from January 1 through February 14. During this time, individuals enrolled in a Medicare Advantage plan can disenroll from their plan and return to Original Medicare coverage.

There are other reasons as well why a person could be eligible during the rest of the year for a special enrollment period outside of the Open Enrollment period. Different Medicare subsidies provided by the state you live in, or the federal government, such as LIS (Low Income Subsidy is also known as Extra Help) and state-specific pharmaceutical programs, can sometimes create a special enrollment. There are many other reasons why a person could qualify for a special enrollment period. One of our agents would have more details on these special enrollment requirements and could help you to decide if you qualify for one.

Medicare Advantage plans are a contract between you and the insurance company. Typically once enrolling, the plan will last for the entire year (January 1-December 31). In general, it is a good idea to stay within the plan you enroll in for the entire coverage period, as disenrolling from the program generally places you back into just having original Medicare. This would also if enrolled in an MAPD plan, disenroll you from a part D prescription drug plan, and if you do not qualify for a special enrollment period, would leave you without the coverage until the next open enrollment period.

Medicare Advantage plans are an option to consider when choosing a Medicare plan. Because of their richness in benefits, and their all in one kind of programs, it makes it easy to understand your potential out of pocket costs, and also provides you with the coverage you might need like Dental, Vision, Hearing, and other supplemental benefits according to plan specifics. The unknown unlimited 20 percent that is potentially what original Medicare offers, is a scary number to think about, as this is an unlimited 20 percent that would be required if you only had original Medicare. Medicare Advantage would take away this unknown and assures you could know what your potential costs could be.

One more thing to note is that Medicare Advantage plans offer coverage’s that vary depending on where you live. This being said, Medicare advantage companies have the right to offer coverage in the specific counties they want to do business in. Depending on where you live, would depend on which plan and through what carrier coverage might be available. Please give us a call to find out what plans are available in your location.

When can I sign up for Medicare Part D coverage or a Medicare Advantage plan?

As mentioned, you do not have to enroll in Medicare Part D coverage. That decision will not affect the Original Medicare coverage. If you are currently taking medications, or feel that in the future, this may be a coverage that you will need, it may be beneficial for you to enroll in a part D plan. You can enroll in either, a stand-alone Medicare Part D Prescription Drug Plan, or enroll in a Medicare Advantage Prescription Drug plan (Medicare Part C), which includes your Medicare Part D benefits to get help with your prescription drug costs. If you do not sign up for Part D, you may have to pay for your medications out of pocket unless you have other insurance.

It is a good idea to sign up for Medicare Part D as soon as you are first eligible for Medicare. If you choose to enroll in a Medicare Part D plan later, or go 63 consecutive days or more without Medicare Part D prescription drug coverage, you may have to pay a late-enrollment penalty. This penalty is charged unless you can show that you had creditable prescription drug coverage during the time you were not enrolled in Part D. Creditable prescription drug coverage is coverage that pays at least as much as Medicare’s standard Part D prescription drug coverage. For example, health coverage you may get through your employer may be considered creditable prescription drug coverage. Your insurance should let you know every year whether your coverage is credible; if you are not sure, you should contact your insurance company to make sure your current coverage is credible under Medicare rules.

As mentioned, you must first have Medicare Part A and/or Part B to be eligible to enroll in a Medicare Prescription Drug Plan, and you must have both Medicare Part A and Part B to enroll in a Medicare Advantage Prescription Drug plan. You are first eligible to sign up for Medicare Part D coverage during your Initial Enrollment Period (IEP) for Part D, which typically takes place during the same seven-month period as your Initial Enrollment Period for Original Medicare. This is the seven-months that starts three months before you turn 65, includes your birthday month and ends three months later. A good time to sign up for Medicare prescription drug or Medicare Advantage coverage is usually as soon as you are enrolled in Original Medicare.

You can also sign up for Medicare Part D coverage during the Annual Election Period (AEP), sometimes called the Fall Open Enrollment or Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage. This takes place from October 15 to December 7 of each year. During this period, you can:

  • Enroll in a Medicare Part D Prescription Drug Plan or change from one Prescription Drug Plan to another.
  • Disenroll from your Medicare Prescription Drug Plan (if you are already enrolled in one).
  • Enroll in or switch Medicare Advantage Prescription Drug plans.
  • Disenroll from your Medicare Advantage plan and return to Original Medicare.

Once you have enrolled in a plan during the open enrollment, your coverage will start on the first of the year. After the Annual Election Period is over, you will have one more chance to make changes to your Medicare Part D coverage. Medicare Advantage Open Enrollment Period runs from January 1 – March 31 every year. If you are enrolled in a Medicare Advantage plan, you will have a one-time opportunity to:

  • Switch to a different Medicare Advantage plan
  • Drop your Medicare Advantage plan and return to Original Medicare, Part A and Part B
  • Sign up for a stand-alone Medicare Part D Prescription Drug Plan (if you return to Original Medicare). Most Medicare Advantage plans include prescription drug coverage already. Usually you cannot enroll in a stand-alone Medicare Prescription Drug plan, if you already have a Medicare Advantage plan, but there are some situations where you can.

If you are enrolled in a Medicare Advantage plan, you can use the Medicare Advantage Disenrollment Period (January 1 to February 14) to disenroll from your Medicare Advantage plan and return to Original Medicare. Then, regardless of whether your Medicare Advantage plan included prescription drug coverage, you can also use this same period to enroll in a stand-alone Medicare Prescription Drug Plan. These are the only changes you can make during this period.

In general, you can only enroll in a Medicare Prescription Drug Plan or make changes to your Part D coverage during one of the above periods. However, some situations qualify you for a Special Election Period (SEP), when you can enroll in a Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan outside of the Annual Election and Open Enrollment periods. Some examples of situations that may qualify you for a Special Election Period include, but are not limited to, moving outside of your plan’s service area or qualifying for state Medicaid or prescription drug help. A Special Enrollment Period (SEP) can take place any time of the year that you have a qualifying situation. If you are not sure whether you have a situation that applies, please feel free to give us a call; a licensed insurance agent would be happy to help you figure out what your options may be.

Medicare Advantage SNP

Medicare Advantage SNP’s are a type of Medicare Advantage plan (like an HMO or PPO). Medicare Advantage SNPs limit membership to people with specific diseases or characteristics. Medicare Advantage SNP’s tailor their benefits, provider choices, and drug formularies to meet the specific needs of the groups they serve.

There are two main types of Medicare Advantage SNP plans. These two types are Medicare Advantage SNP for Dual Eligible Medicare and Medicaid/QMB recipients, and sometimes SLMB recipients, and Medicare Advantage SNP for individuals with a chronic health condition.

Plans targeting people simultaneously enrolled in Medicare and Medicaid, known as Dual Eligible Special Needs Plans, may assist with the coordination of Medicare and Medicaid services. These plans might include benefits that are not covered under the Medicare and Medicaid/QMB programs. This can be additional benefits over and above what Medicare and Medicaid/QMB will pay. These may include but are not guaranteed and are not limited to:

  • Dental
  • Vision
  • Hearing
  • Over the Counter Allowance
  • Rides to your doctor
  • Fitness benefits
  • Nursing hotline


If you have Medicare and full Medicaid coverage, most of your health care costs are likely covered. The Medicare advantage SNP for Dual Eligible individuals will cover supplementary benefits over and above what Medicare and MedicaidQMD covers. 

The Medicare Advantage SNP for individuals that have a specific health condition that fall into the characteristics needed to enroll in the program can help with care specific to the health condition that deems a person eligible for the program. Medicare Advantage Special Needs Plans provide more specifically to the needs of people with specific chronic conditions: 

  • Dependence issues with alcohol or other substances
  • Autoimmune disorders
  • Cancer
  • Cardiovascular disorders
  • Chronic heart failure
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-Stage Renal Disease (ESRD) that requires dialysis
  • Severe hematologic disorders
  • HIV/AIDS
  • Chronic lung disorders
  • Strokes

There are also Special Needs Plans that can be available to people who reside in a long-term care facility such as a skilled nursing home. Each Medicare SNP is designed to offer some unique benefits designed to serve the population for whom that plan is designed. For example, a Medicare SNP for beneficiaries who have a chronic lung disorder may include: 

  • A network of providers who specialize in treating lung conditions 
  • Additional coverage for the type of prescription medications that are used to treat lung disorders 
  • A care coordinator who helps members stay on track with their appointments, medications, diet and exercise programs and more
  • Clinical trials or certain types of alternative medicines and therapies 

In addition to the tailored benefits, Special Needs Plans provide all the same basic coverage as Original Medicare (Part A and Part B). A Medicare Advantage SNP may also offer benefits such as coverage for dental, hearing and vision care, as well as prescription drug coverage.

Medicare SNP Eligibility

To be eligible for a Special Needs Plan, you must first be enrolled in Original Medicare A and B and live in the area served by your desired plan. The additional requirements for each type of SNP plan may include: 

  • Dual-Eligible SNP’s (D-SNP) – You must provide your Medicare and Medicaid QMB enrollment verification. 
  • Chronic Condition SNP’s (C-SNP) – You must have a doctor’s note confirming you have the health condition addressed by the plan.
  • Institutional SNP’s (I-SNP) – You must reside for at least 90 days in a long-term care facility that is served by the plan, or you must meet your state’s guidelines for needing nursing-level care at home for at least 90 days.

Please give us a call to find out what plans are available in your location. 

866-537-3977