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Medicare Advantage Part C

Medicare Advantage 

If you have read other pages on this site, then you are most likely aware that Medicare comes in parts. Original medicare Parts A & B is a primary way in which you can receive your medicare coverage. When receiving original medicare you must also purchase a stand-alone prescription drug plan called Part D. Another way of receiving your medicare is through what is known as Part C or “Medicare Advantage”.

 

What Is Medicare Advantage Part C?

First of all, we will tell you what Part C is not. Medicare Advantage Part C is not something that you enroll in through Social Security like you must do to receive Part A & B. Part C is an alternative way to receive your medicare instead of through Original Medicare.

 

Medicare Part C Advantage Plans Background

 

Medicare Advantage Part C plans are private insurance companies that have a federal contract with the Centers for Medicare and Medicaid (CMS). These plans are hired by the government to pay for your medicare claims instead of original medicare. It is as if the government has hired a subcontractor to perform work under their guidelines. How does this work? Each year the Centers for Medicare and Medicaid (CMS) performs an intensive cost study in each county in the US to determine what the government will offer any private insurance company that wants to provide Medicare Advantage plans in certain areas. Any private insurance company that receives a federal contract is approved by CMS and must provide all the Medicare Part A & Part B benefits to any medicare beneficiaries enrolling in their plan. After receiving a federal contract the private insurance carrier is paid by the Centers for Medicare and Medicaid on a monthly basis for every medicare beneficiary they enroll whether the enrolled beneficiary utilizes healthcare services or not. Medicare Advantage plans may receive additional “bonus” money if their plan achieves certain “star ratings” set by the government based upon the plan’s quality and performance. In other words the to achieve high star ratings, the plan must receive high marks from its members for the plans services and care, how well the doctors in the plan detect illnesses and keep members healthy and other areas such as customer service. Medicare Part C advantage plans generally package Medicare Parts A, B & D together into one plan and it is thus called Part C. There are some Part C plans that you may purchase that carry only Part A & B however those offerings are for rare situations such as when someone already has stand-alone Part D Prescription Drug coverage.

 

More About Medicare Advantage Part C Plans – What to Expect:

Upon choosing a plan and enrolling the medicare beneficiary receives a member ID card, a copy of the plans drug formulary, a directory of network providers and an evidence of coverage documents from the private insurance carrier. On becoming a member, you must utilize the plans network of providers to access their healthcare except in an emergency or for urgent care. In this way Medicare Advantage plans can reduce your deductibles and out of pocket healthcare costs. They generally have a low or even $0 monthly premium as an incentive to enroll. Since private insurance carriers are often more efficient than government programs, they not only cover Part A & Part B but also provide additional benefits beyond what original medicare covers. For example some part c plans include coverage for dental, vision & eyewear, transportation to doctor visits, hearing aids, coverage for over the counter medications not covered by medicare and even gym memberships all at no cost. For this reason, these plans have become very popular, with over 19 million people in the United States receiving their medicare through a medicare advantage part c plan.

 

How Do I Qualify for a Medicare Advantage Part C Plan?

example

  • To qualify for a medicare advantage part c plan you must have both Medicare Parts A and B
  • You must Live in the Plan’s Service Area.
  • If you have end stage renal disease (ESRD) you can only join a Medicare Advantage plan in certain situations.

 

Medicare Advantage Plans:

  • Are also called Part C plans
  • Must include everything that Original Medicare covers and may add additional benefits like Part D prescription drug coverage, eyewear, dental, fitness and more.
  • Are offered by private insurance companies approved by Medicare through the Centers for Medicare and Medicaid (CMS)
  • Are not Medicare Supplement or Medigap plans.

 

If You Choose A Part C Medicare Advantage Plan:

You may have choices like:

 

  • An (HMO) Health Maintenance Organization which requires that you utilize doctors in their network. You must receive a referral and/or authorization before seeing a specialist.
  • A Health Maintenance Organization with a Point of Service – ( HMO-POS). These organizations allow you to use doctors out of network however you will have lower copays or coinsurance when you utilize in-network providers.
  • A Preferred Provider Organization (PPO) gives the most flexibility and allows you to use doctors and hospitals out of the network, however these plans generally come with higher monthly premiums and higher copays and coinsurance when compared to HMO’s.

 

When Can I Enroll In A Medicare Advantage Part C Plan?

When you are new to medicare or turning 65, you may choose to enroll in a medicare advantage plan. Other than that time period you adhere to the guidelines set by the government for enrolling in Medicare Advantage. The Annual Enrollment Period (AEP) is October 15th to December 7th of every year. During that time you can enroll in or disenroll from a Part C Medicare advantage plan. When you enroll or disenroll during the Annual Enrollment Period (AEP), your coverage changes will become effective on January 1st of the following year. If you qualify for a Special Enrollment Period (SEP) then you may be able to join, switch or drop a Medicare plan during your Special Enrollment Period (SEP). Examples of Special Enrollment Periods are when you move out of your plan’s service area to a new location, you obtain or lose Medicaid eligibility or you qualify for “Extra Help” for medicare prescription drug coverage. You may also qualify to enroll in certain Medicare Advantage plans if you have certain chronic medical conditions that qualifies you for special enrollment. Contact our medicare coverage helpline and speak with a medicare specialist to learn more about these plans and find out if you qualify to enroll now.

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