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What are Medicare Advantage Plans?

A Medicare Advantage Plan is another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are Medicare-approved plans. They’re offered by private companies that must follow rules set by Medicare. Most Medicare Advantage

Plans include Medicare drug coverage (Part D). In many cases, you’ll need to use health care providers who participate in the plan’s network. These plans set a limit on what you’ll have to pay out of pocket each year for services covered under Part A and Part B. Some plans offer non-emergency coverage

out of network, but typically at a higher cost. For certain services or drugs, you may need to get approval (also called prior authorization), from your plan before it covers them. In some cases, you may also need to get a referral to use a specialist.

Remember, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your red, white, and blue Medicare card in a safe place because you might need it later.

If you join a Medicare Advantage Plan, you’ll still have Medicare but you’ll get most of your Part A and Part B coverage from your plan, not Original Medicare.

What are the different types of Medicare Advantage Plans?

• Health Maintenance Organization (HMO) Plan: Go to page 66.
• HMO Point-of-Service (HMOPOS) Plan: May let you get some services out of network for a higher copayment or coinsurance. Go to page 66.
• Medical Savings Account (MSA) Plan: Go to page 67.
• Preferred Provider Organization (PPO) Plan: Go to page 68.
• Private Fee-for-Service (PFFS) Plan: Go to page 69.
• Special Needs Plan (SNP): Go to page 70.

What do Medicare Advantage Plans cover?

Medicare Advantage Plans provide almost all of your Part A and Part B benefits, including most new benefits that come from laws or Medicare policy decisions. Medicare Advantage Plan benefits exclude hospice care and some costs of clinical trials. But if you’re in a Medicare Advantage Plan, Original

Medicare will still help cover your costs for hospice care and some costs for clinical research studies, and benefits that come from laws or Medicare policy decisions that the plan doesn't cover. The plan can choose not to cover the costs of services that aren’t medically necessary under Medicare.

In some instances, where Medicare hasn’t established coverage criteria, plans may also use their own coverage criteria to determine if certain services are medically necessary. If you aren’t sure whether a service is covered, check with your provider before you get the service. If you disagree with a coverage

determination, you can appeal (pages 97–100).

Plans may offer some extra benefits

With a Medicare Advantage Plan, you may have coverage for things Original Medicare doesn’t cover, like fitness programs (gym memberships or discounts) and some vision, hearing, and dental services (like routine check ups or cleanings). Some plans can also choose to cover other benefits, like

transportation to doctor visits, over-the-counter drugs that Part D doesn’t cover, and other health care services. Check with the plan before you join to find out what benefits it offers, how much they cost, and if there are any limitations.

Plans can also tailor their benefit packages to offer additional benefits to certain chronically ill enrollees. These packages will provide benefits customized to treat specific conditions. Although you can check with a Medicare Advantage Plan before you join to find out if they offer these benefit packages, you’ll need to wait until you join the plan to find out if you qualify.

To join a Medicare Advantage Plan you must:

• Have Part A and Part B.
• Live in the plan’s service area.
• Be a United States citizen or lawfully present in the United States.
  

Joining and leaving

• You can join a Medicare Advantage Plan even if you have a pre-existing condition.
• You can join or drop a Medicare Advantage Plan only at certain times during the year. Go to pages 71–72.
• Each year, Medicare Advantage Plans can choose to leave Medicare or make changes in coverage, costs, service area, and more. If the plan decides to stop participating in Medicare, you’ll have to join another Medicare Advantage Plan or return to Original Medicare. Go to page 98.
• Medicare Advantage Plans must follow certain rules when giving you information about how to join their plan. Go to pages 105–106 for more information about these rules and how to protect your personal information.

(Source: 2025 Medicare and You Handbook Pages 61-64)