AWCA Resource Center
AWCA Resource Center

Medicare

Medicare Part C (Medicare Advantage)

Medicare Part C, also known as Medicare Advantage, is an all-in-one private alternative to Original Medicare. These plans bundle Part A, Part B, and usually Part D into a single package. While provided by private insurers, they are strictly regulated and approved by Medicare.

Key Aspects

  • Bundled Coverage: Combines hospital, medical, and often prescription drug coverage.
  • Extra Benefits: Most plans include services not covered by Original Medicare, such as routine dental, vision, hearing, and fitness memberships.
  • Spending Limit: Unlike Original Medicare, these plans have a mandatory Maximum Out-of-Pocket (MOOP) limit. Once reached, the plan pays 100% of covered medical services for the rest of the year.
  • Network-Based: Beneficiaries typically use a specific network of doctors and hospitals (HMO or PPO).
  • To enroll in Part C, an individual must already have Medicare Part A and Part B.

Common Plan Types

  • HMO (Health Maintenance Organization): Usually requires using in-network providers and obtaining referrals for specialists.
  • PPO (Preferred Provider Organization): Offers more flexibility to see out-of-network providers at a higher cost; referrals are typically not required.
  • SNP (Special Needs Plans): Tailored for individuals with specific chronic conditions or those eligible for both Medicare and Medicaid.

Costs & Limits (2026)

  • Monthly Premium: Many plans are $0 premium. Beneficiaries must pay the standard Part B premium ($202.90).
  • Out-of-Pocket Cap: Federal maximum limit for in-network services: $9,250/year
  • Copays: A fixed copay is usually set for doctor visits or specialist services.

Enrollment

You can enroll in, switch, drop, or change a Medicare Advantage Plan. To join a Medicare Advantage Plan, you must be enrolled in both Medicare Part A and Part B:

Enrollment PeriodTimingCoverage StartKey Notes
Initial Enrollment Period (IEP)3 months before and after the 65th birthday month (7 months)Varies by time of application (typically 1st day of birthday month)Must have both Part A and Part B to apply. Next l the AEP.
Annual Enrollment Period (AEP)October 15 – December 7January 1 of the following yearCritical period for maintaining, changing, or dropping existing plans.
Open Enrollment Period (OEP)January 1 – March 31 every yearThe 1st of the month following applicationOnly applicable to those with a Medicare Advantage plan. May switch to a different Advantage plan or return to Original Medicare once during this period.
Special Enrollment Period (SEP)Triggered when qualifying events occurVaries by case; Generally within 2 months from the date of the qualifying eventUsed when your existing coverage suddenly ends, if you relocate out of state, or changes in eligibility.

Automatic Rollover

Your Medicare Advantage plan will automatically renew (rollover) each year without requiring a new application.

  • Review Your ANOC: Be sure to review the “Annual Notice of Change (ANOC)” sent by your insurance provider around September each year. Check for critical changes regarding premiums, copays, provider networks, and prescription drug formularies.
  • Service Discontinuation by Insurer: If your current insurance carrier stops offering services in your area or terminates its contract, your existing plan will automatically end.
  • If you are unsatisfied with your current plan, or if your benefits are reduced or discontinued by the insurance company, you must find a new plan during the Annual Enrollment Period (AEP, Oct 15 – Dec 7) or the Medicare Advantage Open Enrollment Period (OEP, Jan 1 – Mar 31; provided your plan is still active).

How to Buy an Medicare Advantage Plan

Medicare Advantage may be purchased directly using Medicare.gov’s online tool.
  1. Select a Plan Online: Go to Medicare.gov and find various plans and their benefit level.
  2. Check Service Area: Plans are location-specific; ensure the plan is available in a specific county.
  3. Verify Providers: Confirm that preferred doctors and pharmacies are included in the plan’s network.

    * Enroll During Specific Windows: Enrollment must occur during the Initial Enrollment Period or the annual Open Enrollment (Oct 15 – Dec 7).

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Medicare