Free Guide to Medicare Advantage Plans at MD Anderson

What Medicare Advantage Plans Are and How They Differ From Original Medicare

Medicare Advantage plans, also called Part C plans, represent a different way to receive your Medicare benefits. Rather than going through the Original Medicare system (Parts A and B), you can choose to receive your hospital and medical coverage through a private insurance company that has a contract with Medicare. Think of it as an alternative path to the same destination—you're still getting Medicare coverage, but the insurance company manages the plan instead of the federal government.

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The main structural difference comes down to how claims are processed and how much you pay. With Original Medicare, you can see any doctor who accepts Medicare nationwide. With Medicare Advantage, most plans require you to use doctors and hospitals within their network, similar to a health maintenance organization (HMO) or preferred provider organization (PPO). This network requirement is what allows these private plans to often charge lower premiums than Original Medicare combined with a Medigap supplement.

Medicare Advantage plans typically cover everything Original Medicare covers—hospital stays (Part A), doctor visits and outpatient care (Part B), and prescription drugs (Part D). However, the way you pay changes. Instead of a Part B premium paid to Medicare plus potential out-of-pocket costs, you pay the plan's premium (which can be as low as zero dollars per month), a yearly deductible, copays for visits, and coinsurance. Some plans cap your yearly out-of-pocket spending, meaning once you hit that limit, the plan covers everything else for the rest of the year.

For patients considering treatment at MD Anderson Cancer Center, understanding these structural differences matters because your plan choice affects which doctors you can see, what your costs will be, and how referrals work. MD Anderson accepts many Medicare Advantage plans, but not all—and the specific terms vary by plan.

Takeaway: Medicare Advantage is a private insurance alternative to Original Medicare that bundles hospital, doctor, and drug coverage into one plan with potentially lower premiums but restricted networks.

Why MD Anderson Cancer Patients Need to Understand Their Plan Options

MD Anderson Cancer Center in Houston, Texas, treats more than 150,000 patients annually and is consistently ranked among the top cancer centers in the nation. Many of these patients are on Medicare, and the type of Medicare plan they choose has real consequences for their treatment journey. Unlike a routine doctor's visit, cancer care often involves multiple specialists, imaging tests, surgeries, chemotherapy, radiation, and months or years of follow-up care—all of which generate significant costs.

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Your Medicare plan choice determines several critical factors in your MD Anderson experience. First, it determines whether you can see your chosen oncologist. If your preferred doctor at MD Anderson is not in your plan's network, you'll either need to switch plans (if possible), switch doctors, or pay the higher out-of-network rates. Second, it affects your total out-of-pocket costs. Cancer treatment can easily exceed $100,000 to $300,000 in the first year alone. Depending on your plan's deductible, copays, and out-of-pocket maximum, you could pay anything from a few thousand dollars to tens of thousands of dollars.

Third, your plan affects how quickly you can access care. Some Medicare Advantage plans require referrals from a primary care doctor before seeing a specialist. In a cancer diagnosis situation, this referral requirement might seem like an unnecessary delay, but it's part of how these plans manage care. Original Medicare doesn't require referrals, allowing you to go directly to any participating specialist.

Understanding your plan also helps you prepare for the financial side of treatment. If you know you're going to have a high deductible, you can start saving. If you know your plan caps out-of-pocket costs at $7,550 per year, you understand your maximum financial exposure. This clarity reduces stress during an already difficult time.

Takeaway: Your Medicare plan choice directly affects which MD Anderson doctors you can see, what you'll pay, and how quickly you can access specialist care.

How Medicare Advantage Networks Work and MD Anderson's Participation

Medicare Advantage plans operate on a network model. Each plan contracts with specific hospitals, doctors, and other healthcare providers. When you receive care from someone in the network, you pay the plan's negotiated rate. When you go out of network, you typically pay much more—sometimes 40% to 60% more than the in-network rate. Some plans don't cover out-of-network care at all except in emergencies.

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MD Anderson's relationship with Medicare Advantage plans is complex because MD Anderson itself is an in-network provider with many (but not all) plans, but individual doctors at MD Anderson may or may not be in-network depending on the specific plan. For example, you might have a Medicare Advantage plan that contracts with MD Anderson Cancer Center, but your specific oncologist in MD Anderson's lung cancer department might not be participating in your plan. This is because individual physicians negotiate their own participation, and not every physician at every hospital participates in every plan.

The types of Medicare Advantage network structures you'll encounter are:

• HMO (Health Maintenance Organization): You must use doctors and hospitals in the plan's network. You'll need a primary care doctor who coordinates your care, and you'll need referrals to see specialists. Out-of-network care is usually not covered except emergencies.
• PPO (Preferred Provider Organization): You can see doctors in or out of network, but it costs more to go out of network. You typically don't need a primary care doctor or referrals.
• PFFS (Private Fee-for-Service): These plans contract with individual providers rather than having a network. Fewer plans operate this way now.
• SNP (Special Needs Plan): These are specialized plans for people with chronic conditions, disabilities, or low income. Some SNPs focus specifically on cancer patients.

Before choosing a plan or beginning treatment at MD Anderson, you need to verify three things: whether MD Anderson Cancer Center is in-network, whether your specific chosen doctor is in-network, and what your plan's network rules are (do you need a referral, is out-of-network covered, etc.). This information is usually available on the plan's website or by calling their member services line.

Takeaway: Medicare Advantage plans use networks, and even if MD Anderson is in-network, your specific doctor might not be. Verification before starting treatment prevents costly surprises.

Costs Under Medicare Advantage: Deductibles, Copays, and Out-of-Pocket Maximums

Understanding the actual cost structure of a Medicare Advantage plan requires learning specific terminology. These aren't mysterious concepts—they're straightforward numbers that determine how much you pay.

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The yearly deductible is the amount you must pay out of your own pocket before the plan starts paying anything. Medicare Advantage deductibles range from zero to several thousand dollars per year. For example, one plan might have a zero deductible (you pay nothing before the plan kicks in), while another might have a $2,000 deductible (you pay the first $2,000 of care yourself). Once you reach your deductible, the plan starts sharing costs with you.

After you've met your deductible, you'll pay copays and coinsurance. A copay is a fixed dollar amount for a specific service. For example, $40 for a doctor's visit or $15 for a prescription. Coinsurance is a percentage of the cost. For example, you pay 20% of the cost of an imaging test, and the plan pays 80%. For cancer care, this distinction matters. If you're getting a PET scan that costs $3,000, and your plan charges 20% coinsurance, you'll owe $600. If your plan instead charges a $200 copay for imaging, you'll owe $200.

The out-of-pocket maximum is the total amount you could possibly pay in a year under your plan for in-network care. In 2024, the maximum out-of-pocket limit for Medicare Advantage plans is capped by Medicare at $7,550 (for individuals). Some plans have lower limits. Once you reach this maximum, the plan covers 100% of remaining in-network costs for the rest of the calendar year