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What is Medicare Advantage?

Medicare Advantage (“Part C”) is a health insurance program of health maintenance organizations (HMOs), preferred provider organizations (PPOs), and other private plans that substitute for original Medicare Parts A and B benefits. Medicare Part A covers in-patient hospital service expenses except for physicians and surgeons. Part B covers costs of physicians and surgeons, medically necessary outpatient hospital services like laboratory tests, X-rays, and diagnostic procedures, and certain durable medical equipment and supplies. The Centers for Medicare and Medicaid Services (CMS) processes original Medicare claims. Commercial insurers and private HMO and PPO corporations offer Medicare Advantage and receive compensation from the federal government but do not process claims through the CMS.

Medicare Advantage Costs

For those who subscribe to Medicare Advantage plans, Medicare pays the private health insurance plans a set amount every month for each subscriber. Subscribers may have to pay monthly premiums in addition to Medicare Part B premiums, but some companies offer Medicare Advantage plans with no premium in addition to the Medicare Part B premium paid directly to Medicare. Medicare Advantage subscribers generally pay a fixed copayment every time they see a physician rather than meet a deductible and pay coinsurance as under original Medicare. Medicare Advantage plans must offer a benefit package at least equal to Medicare coverage, but they need not cover every benefit in the same way. Plans that require higher patient costs than does Medicare for some benefits can offset them by offering lower costs for others. Private plans may use some excess payments from Medicare for each subscriber to offer supplemental benefits.
In sum, health care insurers contract with Medicare to provide all Part A (hospitalization) and Part B (medical and surgical) benefits by Medicare Advantage plans operated by HMOs, PPOs, PFFS plans, special needs plans, and Medicare medical savings account (MSA) plans. Medicare Advantage plans, not original Medicare, cover the expenses of Medicare services. Most Medicare Advantage plans cover prescription drug expenses.

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