Medicare Advantage (Part C)
The right Medicare Advantage plan starts with your doctors, prescriptions, preferred hospitals and budget—not the extra benefits in an advertisement.
How Part C works
Medicare Advantage is another way to receive your Medicare Part A and Part B benefits. Plans are offered by Medicare-approved private insurance companies and must cover the medically necessary services Original Medicare covers.
Most plans include Part D prescription coverage, and some may offer additional benefits. Provider networks, cost sharing, drug formularies and plan rules vary by plan and location.
You must continue paying your Medicare Part B premium. A plan with a low or $0 additional premium can still have copays, coinsurance, deductibles and other costs when you use care.
The primary comparison
Both can provide strong coverage. The practical difference is usually how the provider network works and how much flexibility you want outside it.
HMO
HMO plans generally require routine care from network providers, except for emergencies, urgent care and out-of-area dialysis.
PPO
PPO plans have preferred networks but generally allow covered care outside the network at a higher cost when the provider accepts the plan.
HMO-POS plans: Some HMO plans include a point-of-service feature that permits certain out-of-network services at a higher cost. The specific rules vary by plan.
Side-by-side
| Plan feature | HMO | PPO |
|---|---|---|
| Provider network | Generally receive routine care in network | Use in-network providers for lower costs; out-of-network care is generally available at a higher cost |
| Primary care doctor | Usually required | Usually not required |
| Specialist referrals | May be required; plan rules vary | Generally not required; plan rules vary |
| Prescription coverage | Usually included | Usually included |
| Out-of-network routine care | Generally not covered, except permitted circumstances | Generally covered at a higher cost when the provider accepts the plan |
| Prior authorization | May apply to certain services | May apply to certain services |
This is a general overview. Always review the Evidence of Coverage, provider directory and Summary of Benefits for a specific plan.
Plans for specific needs
Special Needs Plans are Medicare Advantage HMO or PPO plans designed for defined groups. Eligibility must be maintained to remain enrolled.
Designed for people who meet the plan's eligibility requirements for certain severe or disabling chronic conditions.
Designed for people who qualify for both Medicare and Medicaid, with benefits and coordination that vary by plan and state.
What matters most
Dental, vision, hearing or allowance benefits can be useful, but they should not outweigh the healthcare details you rely on.
Confirm every important provider—not only the health system—is in the plan network.
Review the formulary, drug tiers, restrictions and preferred pharmacies for your exact medications.
Compare premiums, copays, deductibles and the medical maximum out-of-pocket—not just the monthly premium.
Consider where you spend time and how the plan handles routine care outside its service area.
Personal plan guidance
Justin checks your doctors, hospitals, medications, pharmacy and budget before helping you compare available Medicare Advantage plans.
MedigapRx is based in Fort Lauderdale and provides personal Medicare guidance in Florida and additional licensed states. After enrollment, Justin remains available when coverage questions arise.
Talk With JustinCommon questions
No. You remain enrolled in Medicare, but a Medicare-approved private company administers your Part A and Part B benefits through the plan.
Most do. HMO and PPO members who want drug coverage generally need to choose a Medicare Advantage plan that includes Part D rather than adding a separate drug plan.
Only if the plan's provider rules work for them. Networks can differ by plan and may change, so each doctor and hospital should be checked before enrollment.
No. A $0 plan premium does not eliminate your Medicare Part B premium or the plan's copays, coinsurance and other possible costs.
Changes generally must be made during an applicable Medicare enrollment period. Certain life events may create a Special Enrollment Period.
Your next step
Start with a personal review of your doctors, prescriptions, budget and enrollment timing.
