Medicare Advantage in Minnesota: Medicare Part C Explained

Medicare Advantage, also called Medicare Part C, is an alternative way to receive your Medicare Part A and Part B benefits.

Instead of receiving those benefits directly through Original Medicare, you receive your Medicare-covered Part A and Part B services through a private insurance company that contracts with Medicare.

Most Medicare Advantage plans also include Medicare Part D prescription drug coverage, and plans may offer additional benefits that Original Medicare doesn’t cover.

For Minnesota residents, the important question isn’t simply whether Medicare Advantage is “good” or “bad.” The question is whether a particular plan fits your doctors, hospitals, prescriptions, budget and preferences for receiving health care.

Learn First. Decide With Confidence.

Medicare Part C

What Is Medicare Advantage?

Medicare Advantage is another way to receive your Medicare Part A and Part B benefits.

To join a Medicare Advantage plan, you must have:

  • Medicare Part A
  • Medicare Part B

You also generally must live in the plan’s service area and meet Medicare’s applicable eligibility requirements.

When you enroll in Medicare Advantage:

  • You remain enrolled in Medicare.
  • You keep Medicare Part A and Part B.
  • The Medicare Advantage plan provides your Medicare-covered Part A and Part B benefits.
  • You continue paying your Medicare Part B premium.
  • You may also pay a Medicare Advantage plan premium, depending on the plan.

Medicare Advantage plans are offered by private insurance companies that contract with Medicare.

Does Medicare Advantage Replace Medicare?

No.

Enrolling in Medicare Advantage does not mean you are giving up Medicare.

You remain enrolled in Medicare Part A and Part B.

The difference is how you receive your Medicare benefits.

With Original Medicare, the federal Medicare program pays for covered Part A and Part B services.

With Medicare Advantage, a private Medicare-approved plan provides your Medicare-covered Part A and Part B benefits according to Medicare requirements and the plan’s rules.

What Does Medicare Advantage Cover?

Medicare Advantage plans must cover the medically necessary services that Original Medicare covers.

Depending on the plan, your Medicare Advantage coverage may include:

  • Hospital services
  • Doctors and specialists
  • Outpatient services
  • Preventive services
  • Diagnostic testing
  • Skilled nursing facility care when coverage requirements are met
  • Certain home health services
  • Durable medical equipment
  • Mental health services
  • Emergency and urgently needed care

Medicare Advantage plans may have different deductibles, copayments, coinsurance, provider networks and coverage rules from Original Medicare.

Does Medicare Advantage Include Prescription Drug Coverage?

Most Medicare Advantage plans include Medicare Part D prescription drug coverage.

These plans are commonly called Medicare Advantage Prescription Drug plans, or MA-PDs.

However, not every Medicare Advantage plan includes Part D.

Prescription drug coverage should be evaluated carefully because plans can differ in:

  • Covered medications
  • Formularies
  • Drug tiers
  • Copayments and coinsurance
  • Pharmacy networks
  • Prior authorization
  • Step therapy
  • Quantity limits

Don’t choose a Medicare Advantage plan based only on its medical benefits.

If prescription drug coverage is included, check your actual medications and pharmacies as part of the comparison.

Can Medicare Advantage Offer Benefits Original Medicare Doesn’t Cover?

Yes.

Medicare Advantage plans may offer additional benefits that Original Medicare doesn’t cover.

Depending on the individual plan, additional benefits might include services related to:

  • Dental care
  • Vision care
  • Hearing
  • Fitness
  • Over-the-counter items
  • Transportation
  • Other supplemental benefits

These benefits aren’t the same in every Medicare Advantage plan.

Eligibility requirements, coverage limits, provider restrictions, frequency limits and other conditions can vary.

Never assume that an advertised additional benefit is available in every Medicare Advantage plan or that every beneficiary will qualify for every benefit.

Review the specific plan’s current benefit information.

Do Medicare Advantage Plans Have Provider Networks?

Many do.

Provider-network rules depend partly on the type of Medicare Advantage plan.

HMO Plans

A Health Maintenance Organization (HMO) plan generally requires you to receive non-emergency care from providers in the plan’s network, subject to the plan’s rules.

Some HMO plans may require referrals for certain specialist services.

PPO Plans

A Preferred Provider Organization (PPO) plan generally allows you to receive covered services from both in-network and out-of-network providers.

Your costs can be higher when you use out-of-network providers.

Other Medicare Advantage Plan Types

Medicare Advantage also includes other plan structures, such as:

  • Private Fee-for-Service (PFFS) plans
  • Special Needs Plans (SNPs)
  • Medicare Medical Savings Account (MSA) plans

Availability varies by service area.

Why Is the Provider Network Important?

A Medicare Advantage plan may look attractive based on its premium and benefits but still be a poor fit if your preferred doctors or hospitals aren’t available under the plan’s network rules.

Before enrolling, check:

  • Primary care physician
  • Specialists
  • Preferred hospital
  • Health system
  • Pharmacy
  • Durable medical equipment suppliers
  • Other providers you regularly use

Provider participation can change.

Always verify current network status with the plan rather than relying solely on what was true in a previous year.

Does Medicare Advantage Require Prior Authorization?

It can.

Medicare Advantage plans may require prior authorization before the plan covers certain services, procedures or medical equipment.

Prior authorization means the plan may need to approve the service before you receive it for the service to be covered under the plan’s rules.

Original Medicare generally doesn’t require prior authorization for most services, although there are exceptions.

Prior-authorization requirements vary by Medicare Advantage plan and service.

This is an important factor to consider when comparing Medicare Advantage with Original Medicare.

How Much Does Medicare Advantage Cost?

There is no single Medicare Advantage price.

Your costs depend on the specific plan.

Possible costs can include:

  • Your Medicare Part B premium
  • A Medicare Advantage plan premium, if the plan charges one
  • Deductibles
  • Copayments
  • Coinsurance
  • Prescription drug costs
  • Out-of-network costs when applicable

Some Medicare Advantage plans have a $0 additional monthly plan premium.

That does not mean your Medicare coverage is free.

You generally must continue paying your Medicare Part B premium, and the plan can have copayments, coinsurance, deductibles and other out-of-pocket expenses.

Compare the total potential cost of coverage—not simply the monthly plan premium.

Does Medicare Advantage Have a Maximum Out-of-Pocket Limit?

Yes.

Medicare Advantage plans have an annual maximum out-of-pocket limit for covered Medicare Part A and Part B services.

Once you reach your plan’s applicable maximum for those covered services, the plan pays 100% of covered Part A and Part B services for the remainder of the year, subject to Medicare requirements and the plan’s terms.

The actual maximum out-of-pocket amount can vary by plan.

This is different from Original Medicare by itself, which does not have an annual maximum out-of-pocket limit for Part A and Part B services.

Prescription drug spending is governed by separate Part D rules and isn’t simply combined with the Medicare Advantage medical maximum out-of-pocket calculation.

Medicare Advantage vs. Original Medicare

Medicare Advantage and Original Medicare are two different ways of receiving Medicare coverage.

Original Medicare

With Original Medicare:

  • The federal government administers your Part A and Part B coverage.
  • You can generally use any doctor or hospital in the United States that accepts Medicare.
  • You can generally add a standalone Part D prescription drug plan.
  • You may purchase Minnesota Medicare Supplement insurance to help with certain Original Medicare out-of-pocket costs.
  • Original Medicare itself doesn’t have an annual Part A and Part B maximum out-of-pocket limit.
  • Prior authorization generally isn’t required for most services.

Medicare Advantage

With Medicare Advantage:

  • A private Medicare-approved plan administers your Part A and Part B benefits.
  • Most plans include Part D prescription drug coverage.
  • Many plans use provider networks.
  • Prior authorization may apply to certain services.
  • Plans may provide additional benefits not covered by Original Medicare.
  • Plans have an annual maximum out-of-pocket limit for covered Part A and Part B services.
  • Premiums and cost sharing vary by plan.

Neither approach is automatically right for everyone.

Your health care needs and preferences should drive the comparison.

Can You Have Medicare Advantage and Medicare Supplement at the Same Time?

Medicare Supplement insurance—also called Medigap—is designed to supplement Original Medicare, not Medicare Advantage.

A Medicare Supplement policy cannot be used to pay your Medicare Advantage plan’s:

  • Copayments
  • Coinsurance
  • Deductibles
  • Premiums

It is generally illegal for someone to sell you a Medicare Supplement policy while you’re enrolled in Medicare Advantage unless you’re switching back to Original Medicare and the Supplement coverage will begin after your Medicare Advantage coverage ends.

Important Minnesota Medicare Supplement Consideration

Minnesota residents should be particularly careful before dropping existing Medicare Supplement coverage to join Medicare Advantage.

Minnesota standardizes Medicare Supplement coverage differently from most states and has Minnesota-specific Medicare Supplement enrollment rights.

Federal law also provides certain trial rights in specified situations.

For example, if you join Medicare Advantage for the first time and decide it isn’t right for you, federal law provides certain rights to return to Original Medicare and obtain Medicare Supplement coverage when the applicable requirements and deadlines are met.

Minnesota law may provide additional Medicare Supplement enrollment protections.

Because these rights depend on the specific circumstances and timing, verify your Medicare Supplement rights before cancelling an existing policy.

Do not cancel Medicare Supplement coverage merely because you have submitted a Medicare Advantage application without first understanding when the new coverage becomes effective and what rights you would have if you later return to Original Medicare.

When Can You Enroll in Medicare Advantage?

You can’t generally join or change Medicare Advantage plans whenever you want.

Medicare establishes specific enrollment periods.

Initial Enrollment Period

When you’re first becoming eligible for Medicare, your Initial Enrollment Period generally begins 3 months before you get Medicare and ends 3 months after you get Medicare.

You need both Medicare Part A and Part B to join a Medicare Advantage plan.

Coverage effective dates depend on when you enroll.

Medicare Open Enrollment: October 15–December 7

Each year, Medicare’s Open Enrollment Period runs:

October 15 through December 7

During this period, eligible Medicare beneficiaries can:

  • Switch from Original Medicare to Medicare Advantage
  • Switch from Medicare Advantage to Original Medicare
  • Switch from one Medicare Advantage plan to another
  • Make applicable Medicare prescription drug coverage changes

Changes generally become effective January 1 of the following year when the enrollment request is received by December 7.

This period is also commonly called the Annual Enrollment Period (AEP) in the Medicare insurance industry.

Medicare Advantage Open Enrollment: January 1–March 31

If you’re already enrolled in a Medicare Advantage plan, the Medicare Advantage Open Enrollment Period runs:

January 1 through March 31

During this period, you can generally make one change:

  • Switch to another Medicare Advantage plan, with or without drug coverage; or
  • Leave Medicare Advantage and return to Original Medicare.

If you return to Original Medicare, you can also join a standalone Medicare Part D plan.

If you’re in Original Medicare, you cannot use this period to join Medicare Advantage.

Changes generally take effect the first day of the month after the plan receives the enrollment request.

Special Enrollment Periods

Certain events can create a Special Enrollment Period (SEP) that allows you to make a Medicare Advantage change outside the normal annual enrollment periods.

Examples can include:

  • Moving outside your plan’s service area
  • Moving somewhere with different plan choices
  • Losing certain other coverage
  • Changes in Medicaid eligibility
  • Qualifying for certain Extra Help provisions
  • Moving into or out of certain institutions
  • Certain changes involving your Medicare plan

The exact enrollment opportunity and deadline depend on the event.

Don’t assume every move or coverage change creates the same SEP.

Medicare Advantage Plans Are Local

Medicare Advantage plan availability is based on service area.

That means a plan available in one Minnesota county may not be available in another.

Even plans offered by the same insurance company can differ by service area.

For this reason, a meaningful Medicare Advantage comparison requires your actual Minnesota residence and the plans available in that service area.

YourMedicareMN does not assume that a plan available elsewhere in Minnesota is available where you live.

Medicare Advantage Plans Can Change Every Year

Medicare Advantage plans operate on a plan-year basis and can make changes from one year to the next within Medicare requirements.

Changes can involve:

  • Premiums
  • Deductibles
  • Copayments
  • Coinsurance
  • Maximum out-of-pocket amounts
  • Provider networks
  • Prescription drug formularies
  • Pharmacy networks
  • Prior authorization requirements
  • Additional benefits

Your plan sends an Annual Notice of Change (ANOC) describing applicable changes for the next plan year.

Review it every year.

A plan that works well for you this year should not automatically be assumed to be the best fit next year.

What Should You Compare Before Choosing a Medicare Advantage Plan?

Don’t choose a plan based on one feature.

Consider the entire plan.

Doctors

Are your doctors and specialists in the plan’s network?

Hospitals

Are the hospitals and health systems you prefer available under the plan’s rules?

Prescription Drugs

Are your medications covered, at what tier and through which pharmacies?

Premium

Does the plan charge an additional monthly premium?

Out-of-Pocket Costs

What are the deductibles, copayments and coinsurance?

Maximum Out-of-Pocket

How much could you potentially spend on covered Part A and Part B services during the year?

Prior Authorization

Which services require plan approval?

Travel

How does the plan cover routine, urgent and emergency care when you’re away from home?

Additional Benefits

Are dental, vision, hearing or other supplemental benefits important to you, and what are their actual coverage limits?

Plan Type

Is the plan an HMO, PPO or another type, and are you comfortable with its rules?

Is a $0 Premium Medicare Advantage Plan Free?

No.

A $0 plan premium means the Medicare Advantage plan doesn’t charge an additional monthly plan premium.

It doesn’t mean you have no Medicare costs.

You generally still pay your Medicare Part B premium and may have:

  • Deductibles
  • Copayments
  • Coinsurance
  • Prescription drug costs
  • Other plan cost sharing

A $0-premium plan may be appropriate for some people, but the premium alone doesn’t tell you whether the plan is a good value for your circumstances.

Is Medicare Advantage Right for You?

There isn’t one answer that applies to everyone.

Medicare Advantage may appeal to someone who values features such as:

  • Receiving Medicare benefits through one private plan
  • Integrated prescription drug coverage in many plans
  • An annual medical maximum out-of-pocket limit
  • Additional benefits offered by a particular plan

Other people may prefer Original Medicare because of considerations such as:

  • Broader nationwide provider access
  • Fewer network restrictions
  • Generally less reliance on prior authorization
  • The ability to combine Original Medicare with Minnesota Medicare Supplement coverage

These are comparison considerations, not guarantees that one form of Medicare is better than another.

The right choice depends on your circumstances.

Next Steps in Minnesota

  • Compare Medicare Advantage plans available in your county
  • Review plan networks to ensure your preferred doctors and hospitals are included
  • Check if prescription drugs and extra benefits meet your needs

YourMedicareMN can help you compare plans, understand Minnesota-specific rules, and enroll in the best Medicare Advantage plan for you.

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Visit Contact Us to schedule a personalized Medicare review and get answers tailored to your situation.

For official Medicare information, visit the Medicare.gov website.

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