Medicare Part C, or Medicare Advantage, is coverage from a private insurance company. These plans can offer an array of benefits ranging from dental, vision, hearing, and gym memberships. Many Part C plans have a $0 premium, so it’s easy to see what attracts people to these plans. But, even with all the perks, there are downfalls to Medicare Advantage.
What is Medicare Part C?
When you choose a Medicare Advantage plan, a private company will handle your benefits and claims instead of the federal government. The policy must cover at least as much as Medicare. Unless you go out of the network.
Those with a Health Maintenance Organization policy will pay 100% out of pocket when they leave the network. But, if you have a Preferred Provider Organization plan, there will be some coverage. In some cases, you pay 40% of the cost out of the network.
Also, there are Health Maintenance Organization Point of Service policies that allow you to see some doctors out of network at a higher rate. The Private Fee for Service policies require you to call the doctor before services are rendered to ensure coverage is still available, you must do this EVERY time before an appointment. For those that have low-income or chronic issues, Medicare Advantage Special Needs plans can help. But, you must live in the service area of the plan to qualify.
Listen to this Podcast Episode Now!What Does Medicare Part C Cover?
Part C must cover all services that have coverage under Part A and Part B. Most plans include more than Medicare. Also, many Part C plans cover preventive care and prescription drugs; some offer dental and vision benefits. Some plans even include over the counter medication benefits.
If you’re in a Private-Fee for Service (PFFS) plan without drug coverage, you can add drug coverage by enrolling in a Part D plan. No matter which policy you choose, it’s important to verify the Part D formulary.
Over 90% of Advantage plans include transportation assistance, and over 95% cover a meal benefit. Also, some plans include telehealth services or in-home support. Further, some Medicare Advantage plans offer Part B give-back option that lowers or eliminates your Part B premium costs.
Some Medicare Advantage plans now cover Long Term Care benefits. These benefits aren’t mandatory, so not all plans offer them. But, there may be plans in your area that include these benefits.
But, just because everyone else is doing it, doesn’t mean it’s best for you. There is a reason people talk about why Medicare Advantage plans are bad. Before you choose your policy, compare Medigap and Advantage, so you know you’re getting the best value for you.
Eligibility for Part C
You must have Both Part A and Part B to be eligible for Part C. The one health question that can disqualify you for a Medicare Advantage plan is, “do you have End-Stage Renal Disease?” Unless you develop End-Stage Renal Disease when you’re already on a Medicare Advantage plan, you won’t be able to select this coverage.
If you already have Medicare Advantage when you develop ESRD, you might be able to select a different plan with the same company. Also, if the plan leaves the area, you’ll have a one-time right to choose another policy.
Further, if an ESRD Special Needs Plan is available in your area, you may join. Also, if you have a successful kidney transplant and no longer have ESRD, you’ll qualify for Medicare Advantage coverage.
CMSnewsroom claims ESRD patients will have access to Medicare Advantage plans by 2021 or 2022.
Medicare Part C vs Original Medicare
Under Part A and B, there are no provider networks; so, you can go to any doctor or hospital you want, so long as they accept Medicare.
Private insurance companies offer Part C through HMOs and PPOs. For each, there’s a list of “in-network” healthcare providers.
If you go to a provider out of the network, your claim may not have coverage, or you’ll pay more for services.
By comparing Medicare Advantage vs. Medicare Supplement side by side, you can figure out which you prefer.
How Much Does Part C Cost?
Many Advantage plans have a $0 premium. But, some areas have a higher premium costing plan. The average Medicare Advantage plan cost is about $23 a month. Of course, your location is the determining factor in the plans available to you.
When you live somewhere that has little to now quality plan options, consider the benefits of Medigap.
What happens if you find yourself disenrolled from your Medicare Advantage plan?
Single Grace Period – If one or more payments have gone unpaid during your grace period, the plan can discontinue coverage.
Rollover Grace Period – If you owe more than one premium but manage to pay for a minimum of one premium during your grace period, the period will end, and your plan will notify you of a new grace period.
Notifications continue until you catch up on premiums. But, if you fail to make a premium payment during this time, you face dis-enrollment.
FAQs
How to Enroll in Medicare Part C
At MedicareFAQ, we help you navigate the world of Medicare. We'll explain the pros and cons of your options and research all the top providers in your area. We can look at your Medicare Advantage checklist to find the policy that is most suitable for you.
An agent can ask you a few questions about your needs and wants in a policy. Then, they can help you identify the plan with the most value for you.
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My wife is on Medicare, retired, no major health issues. She has coverage through AARP. We are trying to find one that will give back the $148 taken from her check. Losing the $148 is a hardship. We live in Florida, where no Medicaid is to pay for the cost.
Hi Rhonda! It depends on your zip code. The give-back benefit is only available in some areas.
Hi, I am looking into medical benefits on behalf of a loved one. They have Rheumatoid Arthritis and require what most insurances classify as “specialty” medication. Due to this classification Medicare, and their supplemental plans will not cover the RX to a reasonable amount. By reasonable I mean typically affordable for an average individual. The base price of a months supply for the prescription in question is around 6,000 dollars. With their current plan my loved one would still end up paying over $1,500 a month for their medicine. Which is impossible when she is living off of $1,000 a month. My question is what kind of drug coverage can be found using an Advantage plan? Would it be worth it to have her look into this?
Hi Dayna! You can use the Medicare plan comparison tool to type in the medication and see what Medicare Advantage plans will cover it. It will also show you other Part D plans that may cover it. There is a donut hole with Part D.
will i still qualify for the part B give back option if i qualify for the extra help from medicare?
Hi Oscar! As long as you don’t have a Medicare Savings Program that helps you pay the Part B deductible, you will qualify. I don’t believe Extra Help will make you ineligible.
Lindsay:
We are located in California. How much does Medicare pay out for a Senior Citizen on their Medicare Advantage plan. Is it taken out of the Senior’s Social Security Benefit?
Hi Steven! It depends on your zipcode and the carrier you choose to enroll with. You can read more about the Part B give-back benefit here.
Hi Lindsay,
Can you tell me if a Medicare Advantage has the authority to request prior authorization for services covered under an NCD-CED?
Thank you,
Lori
Hi Lori. I would imagine the carrier does have the authority to request prior authorization. You can read more on CMS coverage with evidence development.
I have a question. Does medicine pay a premium for those using an advantage plan? My understanding is that Medicare pays a premium to insurance companies for administering advantage plans so the cost is higher then go conventional Medicare
Hi Richard! Medicare does pay the Medicare Advantage carrier to take on your risk. However, you still must pay the monthly premium for Part B. Some Medicare Advantage plans come with a premium reduction benefit to help with this.