Part C
Medicare Advantage, without the sales pitch.
One private plan in place of Parts A and B, usually with drugs bundled in, almost always with a network — and, crucially, with a hard annual ceiling on what in-network care can cost you.
How it actually works
Four things are true at once.
Most confusion about Advantage comes from people being told one of these and not the other three.
-
You stay in Medicare
You must be entitled to Part A and enrolled in Part B, and you keep paying the Part B premium. Advantage is a delivery mechanism, not an exit.
-
A private plan takes over the administration
A carrier contracts with CMS to provide your Part A and Part B benefits. By law it must cover everything Original Medicare covers, except hospice, which stays with Part A.
-
The plan sets the rules of access
A network of doctors and hospitals, a service area, and — for many services — prior authorisation. HMOs generally require referrals; PPOs allow out-of-network care at a higher share.
-
Everything resets on 1 January
Networks, formularies, copays, extra benefits and the maximum out-of-pocket can all change with the new plan year. The Annual Notice of Change that lands each autumn is the document that tells you how.
What it costs
A low premium is not a low cost.
Advantage plans move money from the fixed column to the variable one. You pay less each month and more when you use care, and the MOOP is the number that says how bad the worst year can get.
- Part B premium
- Always. Set by CMS each year, plus IRMAA if your income is above the threshold. This does not go away.
- Plan premium
- Often $0, sometimes not. A $0 premium is a marketing fact, not a cost analysis.
- Copays and coinsurance
- Per visit, per test, per admission, per day for the first few hospital days. This is where the real spending happens.
- Maximum out-of-pocket
- The ceiling on in-network Part A and B costs for the year. CMS sets the highest allowed figure; plans may go lower. Out-of-network costs on a PPO usually sit under a separate, higher limit.
- Drug costs
- If the plan includes Part D, its own deductible, tiers and pharmacy network apply — and they are not the same across plans from the same carrier.
Star Ratings
The only quality signal that is not marketing.
CMS rates every Medicare Advantage and Part D plan from one to five stars each autumn, for the following plan year. The rating weighs around forty measures — how well the plan manages chronic conditions, how members rate their care, how the plan handles customer service, how many complaints it generates and how many members leave.
It is not a perfect instrument, but it is the only one produced by someone with no plan to sell. A 4.5-star plan and a 3-star plan with the same copays are not the same product.
- 5 stars · Excellent Rare. Triggers the year-round Special Enrollment Period.
- 4 stars · Above average The band most competitive plans sit in.
- 3 stars · Average Worth asking why, especially on member experience.
- 2 stars · Below average Three consecutive low-rated years and CMS may terminate the contract.
Who it fits
Honest on both sides.
We would rather you read the second column now than discover it in March.
It tends to work well if
- Your doctors and your hospital are already in the network, and you are not planning to move.
- You want a ceiling on a bad year and would rather not pay a Medigap premium every month to get one.
- Dental, vision, hearing or a fitness benefit are things you would otherwise buy separately.
- You are comfortable reviewing the plan every autumn when the Annual Notice of Change arrives.
- You qualify for Extra Help or a Special Needs Plan that is built around a condition you have.
It tends to work badly if
- You split the year between two states, or travel for months at a time.
- You see a specialist at a centre that is out of network, and would not change.
- You have a condition where prior authorisation delays would genuinely matter.
- You want the same coverage in ten years that you have today, without an annual review.
- You may want a Medigap policy later — outside guaranteed-issue windows you can be medically underwritten, and health changes.
Before you enrol
Five checks, in this order.
- Your doctors. Every one of them, by name, on the plan’s own directory — not a search aggregator. Then call one office and confirm.
- Your hospital. Networks can include the physicians and exclude the facility, or the reverse.
- Your prescriptions. Each drug, each dose, against the plan’s formulary, including which tier and whether it needs prior authorisation or step therapy.
- The maximum out-of-pocket. In-network and, on a PPO, out-of-network. This is your worst case, so read it as one.
- The Star Rating, and specifically the member-experience measures underneath it.
Asked often
- Do I keep paying the Part B premium on a Medicare Advantage plan?
- Yes. A Medicare Advantage plan does not replace Part B, it replaces the way you receive Part A and Part B benefits. You keep paying the Part B premium, and any plan premium is on top of it. Many Advantage plans carry no premium of their own.
- What is a MOOP?
- The maximum out-of-pocket: the most a Medicare Advantage plan can make you pay in a calendar year for in-network Part A and Part B services. CMS sets the highest figure a plan is allowed to use and resets it each year; plans may set a lower one. Original Medicare has no equivalent, which is the main structural argument for Advantage.
- Does Medicare Advantage cover hospice?
- Hospice stays with Part A even while you are enrolled in an Advantage plan. Original Medicare pays for hospice care directly; your plan continues to cover everything else.
- Can I be turned down for a Medicare Advantage plan because of my health?
- No. Advantage plans cannot use medical underwriting. If you are entitled to Part A, enrolled in Part B and live in the plan’s service area, the plan must take you during a valid enrollment period.
Bring us your doctor list and your prescriptions.
That is the whole conversation. Fifteen minutes with the two things that actually decide it, and no attempt to move you off the answer they produce.