LibGuides: Medicare Law: Medicare Advantage (Part C)

Introduction

The Medicare Advantage program - also known as Medicare Part C - offers beneficiaries the option of receiving all of their Medicare benefits from health plans run by private companies.

The cheapest Medicare Advantage plans generally cost zero to around $100 per month. They include pretty much all that's involved in an A plus B plus D plus Medigap custom plan. However, these plans have a managed care system, so you must stay in-network and get referrals to see specialists.

Unlike Medicare Cost Plans, Medicare Advantage plans assume financial risk if payments from Centers for Medicare & Medicaid Services do not cover their costs.

Balance billing is prohibited for Medicare-covered services in the Medicare Advantage program, except in the case of private fee-for-service plans. Fee-for-service plans are more expensive, but allow you to go out of network.

For enrollment periods, see the Medicare Part A page of this guide.

US Code

42 US Code 1395w-21
Medicare Advantage plans are called "Medicare Choice" plans in the statute.

GAO Report

MEDICARE ADVANTAGE Beneficiary Disenrollments to Fee for Service in Last Year of Life Increase Medicare Spending
GAO Report June 2021

CFR

42 CFR Part 422
MEDICARE ADVANTAGE PROGRAM
42 CFR 422.10
Medicare Advantage plans may not deny or limit benefits to individuals eligible to enroll in an MA plan on the basis of any factor that is related to health status, including, but not limited to the following:
(1) Medical condition, including mental as well as physical illness.
(2) Claims experience.
(3) Receipt of health care.
(4) Medical history.
(5) Genetic information.
(6) Evidence of insurability, including conditions arising out of acts of domestic violence.
(7) Disability.

Proposed Rules

Proposed changes to Medicare Advantage
Federal Register 11/2/23

Executive Orders

Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors
10/3/19 Supports expansion of Medicare Advantage, including higher premiuns.

Types of Medicare Advantage Plans

HMO Plans
Covers prescription drugs
PPO Plans
Covers prescription drugs
Private Fee for Service Plans
PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care. Doesn't cover prescription drugs, but can enroll in Part D.
Medicare Medical Savings Account (MSA) Plans
Medicare MSA Plans combine a high-deductible insurance plan with a medical savings account that you can use to pay for your health care costs. Doesn't cover prescription drugs, but can enroll in Part D.
Special Needs Plans
A special needs plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals. A special needs individual could be any one of the following: An institutionalized individual, a dual eligible, or an individual with a severe or disabling chronic condition, such as dementia, as specified by CMS. One key difference between a Special Needs Plan and other types of Medicare Advantage plans is that all Special Needs Plans must cover prescription drugs. In contrast, other Medicare Advantage plans (for example, HMOs and PPOs) may or may not include prescription drug coverage, depending on the specific plan. In addition to the open enrollment period, Special Needs Plan with a Special Election Period in certain situations. Some situations that may qualify you for a Special Election Period to enroll in a Special Needs Plan or make coverage changes include:
You are diagnosed with a severe or disabling condition: You can enroll in a Chronic-Condition Special Needs Plan for beneficiaries with your illness at any time, and your Special Election Period ends once you enroll in the plan.

Medicare Law: Medicare Advantage (Part C)