Medicare Advantage and Other Medicare Health Plans
What to know
Medicare Advantage (Part C) plans are offered by private insurers under contract with CMS and must provide all Part A and Part B benefits (except hospice, which stays under Part A). Plans may be HMOs, PPOs, PFFS, or SNPs (special needs plans for dual-eligible, institutionalized, or chronic-condition beneficiaries). Most MA plans include Part D drug coverage (MA-PD). Key features: networks, prior authorization, formularies, and an annual out-of-pocket maximum that Original Medicare lacks. Enrollees must generally use network providers except for emergencies or out-of-area urgent care; PPOs allow out-of-network care at higher cost. You cannot have a Medigap policy and use it to pay MA cost-sharing in the usual way, and you generally cannot enroll in a stand-alone PDP while in an MA-PD. Other options include Medicare Cost Plans and PACE for certain frail beneficiaries.
Traps
Questions test whether a plan "must" cover a benefit versus "may" offer extra benefits. All MA plans must cover the same core benefits as Original Medicare; supplemental benefits (dental, vision, fitness) vary. SNPs have eligibility restrictions-marketing a chronic-condition SNP to someone who doesn't qualify is a violation. Remember the MA Open Enrollment Period (Jan 1–Mar 31) allows one change, and disenrollment rules matter for those who move or lose eligibility.
Rule of thumb
If a question asks whether an MA plan can deny a service, the answer usually turns on medical necessity and prior authorization-not on whether the benefit exists.