Medicare Part C
What is Part C (Medicare Advantage)?
Part C, also known as Medicare Advantage, is Medicare’s managed care program, which offers plans provided by private insurance companies contracted by Medicare. These plans are referred to as all-in-one plans because they typically include your Part A, B and D benefits.
Important Key Points about Medicare Advantage
✓ To enroll in a Medicare Advantage plan, you must have active Parts A and B.
✓ Medicare Advantage is an alternative to Original Medicare. When enrolling in a Medicare Advantage plan, you no longer have access to benefits under Original Medicare.
✓ To enroll in a Medicare Advantage plan, you must reside in the plan’s service area.
✓ Medicare Advantage plans designs include HMOs, PPOs, POS, PFFS, and MSA.
✓ All Medicare Advantage plans will have a network of contracted providers within their service area. Some plans may require you to get a referral for certain services.
✓ When you enroll in a Medicare Advantage plan, a separate card is provided to you. This is the only card you will need for all of your care (you will not need your red, white and blue Medicare card).
A Closer Look at Part C
To be eligible for a Medicare Advantage plan, you must be:
✓ actively enrolled in both Part A and Part B
✓ live in the plan’s service area
What are the benefits associated with Medicare Advantage?
Medicare Advantage plans are required to offer benefits that are equal to Original Medicare standards. Plans can exceed those benefits found in Medicare Parts A, B and D, but they cannot be reduced below the Medicare standards.
Medicare Advantage plans can provide extra benefits not covered by Original Medicare.
To enroll in a Medicare Advantage plan, you must be:
✓ actively enrolled in both Part A and Part B
✓ live in the plan’s service area
When can you enroll in a Medicare Advantage plan?
✓ During your Initial Coverage Election Period (ICEP), which is the 7-month window that surrounds your 65th birthday. During this enrollment period, you can sign up for a Medicare Advantage plans with or without Prescription Part D coverage.
✓ During a Special Enrollment Period (SEP), if you delayed your Part B enrollment due to having employer coverage, you can elect to enroll into Medicare Advantage.
✓ During the Annual Enrollment Period (AEP) individuals enrolled in Original Medicare can switch to a Medicare Advantage plan, with or without prescription drug coverage.
When can you change your Medicare Advantage plan?
During the Annual Enrollment Period (AEP) individuals enrolled in a Medicare Advantage can switch to another Medicare Advantage plan, with or without prescription drug coverage. You may also return to Original Medicare and add a Part D plan.
During the Medicare Advantage Open Enrollment Period (OEP), individuals enrolled in a Medicare Advantage can switch to another Medicare Advantage plan, with or without prescription drug coverage. You may also return to Original Medicare and add a Part D plan.
Note: You cannot be enrolled in a Medicare Advantage plan and a Medicare Supplement plan at the same time.
What are the costs associated with Medicare Advantage plans?
Medicare Advantage plans will have out-of-pocket costs that include premiums, deductibles, copays and coinsurance. These costs will vary, and plans may have higher or lower out-of-pocket costs associated with covered services.
It is important for you to estimate what your out-of pocket medical and prescription care would cost when enrolling in a Medicare Advantage plan.
Note: You must continue to pay your Medicare Part B premium and IRMAA related charges when enrolled in a Medicare Advantage plan.
Do Medicare Advantage plans have a yearly limit for your medical spending?
All Medicare Advantage plans will have a maximum out-of-pocket limit for covered medical services. Once you reach the plan’s limit, you’ll pay nothing for covered medical services. For 2026, Medicare has set a limit of $9,250 for all plans, although plans may offer a lower limit.
If you enroll in a Medicare Advantage plan with prescription drug coverage, your drug costs will accumulate towards a separate out-of-pocket limit.
Tip: It is important to understand your annual maximum out-of-pocket limit as it is critical when evaluating your plan options each year.
Prior Authorization
What is Prior Authorization?
Prior authorization is a stipulation of Medicare Advantage plans that requires health care providers to obtain approval for certain medical services prior to their delivery. Prior authorization is utilized for cost-savings, not for care.
How does Prior Authorization work?
When your healthcare provider recommends a covered medical service, your provider must obtain authorization from your Medicare Advantage plan before delivering medical services or filling prescriptions. Prior authorizations will be required when seeking care from out-of-network provider, non-emergency hospital care and home health care, durable medical equipment and more.
The impact of prior authorizations can be the delay or denial of care.
It is important to understand what services on your current plan, or a plan you are considering, require prior authorization so you can make the right decisions regarding your Medicare benefits and costs.
What is an Organization Determination?
Organization determination is your ability to find out if your plan covers a service, drug or supply. Either you or your provider can get a decision either verbally or in writing, from your plan in advance of receiving medical care. Your decision can also include how much you’ll have to pay. Sometimes, an organization determination may be required as part of the prior authorization process.
What is Plan Directed Care?
Plan Directed Care is when your Medicare Advantage plan refers you for a service or a provider outside their network, but doesn’t get an organization determination in advance. In most cases, you won’t have to pay more than the plan’s usual cost-sharing for these services. It is important to check with your plan regarding this protection.
Helpful Tips When Considering a Medicare Advantage Plan
✓ Medicare Advantage plans have networks. It is important to confirm your provider’s inclusion in the plan’s provider network.
✓ Find out if the plan requires referrals.
✓ Find out how the plan provides coverage when you leave the service area.
✓ Confirm your prescriptions are included in the plan’s formulary. Also check if your pharmacy is considered a preferred provider.
✓ Understand the maximum out-of-pocket amount associated with in-network care. If your plan has out-of-network benefits, also determine if there is a separate out-of-pocket maximum for these services.
✓ Determine what services require prior authorization.
To join a Medicare Advantage plan, you must continue to pay your Part B premiums, plus any associated IRMAA charges (if applicable).
Understanding Medicare Advantage
Are you overwhelmed by the amount of phone calls and mailers regarding Medicare Advantage plans? Our agents are here to cut through the noise and reduce your stress.
