About Medicare Advantage

Medicare Advantage (Part C) plans provide Medicare coverage through private health insurance companies approved to participate in the Medicare program. Medicare Advantage plans provide all Part A (hospital insurance) and Part B (medical insurance) services as Original Medicare while generally including additional services, such as wellness programs and more. Medicare Advantage plans generally also include prescription drug coverage (Part D). These plans tend to have a maximum out-of-pocket cost and lower overall cost sharing.

Medicare Advantage costs can be broken down into the following categories:

  • Premium: All Medicare Advantage plans require that you continue to pay your Part B insurance premium. You might also have to pay a separate monthly insurance premium for your Medicare Advantage plan.
  • Deductibles: The deductible is amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.  Some plans have deductibles.
  • Copayments: A copayment is the amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug.  A copayment is usually a set amount, rather than a percentage.
  • Coinsurance: Coinsurance is the amount you may be required to pay as your share of the cost for services after you pay any deductibles.  Cost sharing amounts may apply to specific services.
  • Out-of-pocket expenses: All Medicare Advantage plans have an annual limit on your out-of-pocket expenses, which is a feature not available through Original Medicare.

Key areas for providers:

  1. Find Care Tool – Members can use this tool to locate physicians, specialists, health care providers and others that are in the Medicare Advantage network. Providers can also use this tool to determine if a provider they may be referring a patient to is in the Medicare Advantage network.
  2. Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) – BlueCross BlueShield of South Carolina uses LCDs and/or NCDs for claim adjudication. An LCD is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific region that the MAC oversees. NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for a specific medical service procedure or device.
    • The Medicare Coverage Database – This database is on www.CMS.gov and can provide guidance for specific Medicare coverage policies.
  3. Star Ratings – Each year, the Centers for Medicare and Medicaid (CMS) measures how well Medicare plans (medical and Part D prescription drug) perform. The scale used is known as the Star Rating System. Ratings range from one to five stars, with five being the highest score a plan can receive.


Find more information here.

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