What is Medicare Part C?
There are several types of Medicare Advantage plans. The two most common are Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans. HMOs often come with a $0 premium, but only offer coverage if the member receives care from a doctor within the HMO network. PPO plans may have a higher premium, but does offer coverage even outside of the PPO network.
There are also Private Fee-for-Service (PFFS) Medicare Advantage plans. These plans require their members to call their provider prior to treatment to make sure coverage is still available through that provider or facility.
Finally, there are also Special Needs Plans (SNPs). These Part C plans are for individuals with low-income or chronic conditions. Like HMOs, you must live in the plan’s service area to qualify for this type of Medicare Advantage plan.
Medicare Part C Benefits
A Medicare Advantage plan must offer coverage of all services that would be covered under Medicare Parts A and B. However, most Medicare Advantage plans include additional coverage for things like routine dental, vision, and hearing benefits.
Many of them also include prescription drug coverage and over-the-counter medication benefits, though you should inquire about the specific plan’s drug formulary. The drug formulary includes the list of prescriptions covered under the plan and how much each drug will cost the member.
Most Advantage plans offer transportation assistance and meal delivery, as well as gym memberships. Some include the Part B reduction benefit, which reduces the amount the member pays for their Part B premium.
Few Part C plans now include long-term care coverage.
While all of these benefits make Medicare Advantage plans seem like the obvious choice, you should still talk to one of our licensed agents before making this decision.
Medicare Part C Eligibility
Medicare beneficiaries must already be enrolled in Original Medicare to be eligible for Part C. These plans do not require medical underwriting, so nearly everyone is eligible to enroll. However, those with End-Stage Renal Disease are not eligible for a Medicare Advantage plan.
If an individual develops ESRD while enrolled in a Medicare Advantage plan, they may be able to select a different plan with the same carrier. If that plan leaves the service area, the individual will have a one-time right to choose another Medicare Advantage policy.
How does Medicare Part C differ from Original Medicare?
Original Medicare does not have provider networks. Individuals enrolled in Original Medicare can choose to see any provider who accepts Medicare assignment in the United States. Medicare Advantage plans have a list of in-network providers that the member must choose from. Receiving care outside the network could leave the member paying for all costs out-of-pocket, except for in emergency situations.
Individuals will need to compare their Medicare Advantage plan choices to those offered by Medicare supplements.
How much does Medicare Part C cost?
There are many Part C plans that offer coverage for a $0 premium, but the average cost is approximately $23 per month. Of course, there are other costs associated with Part C plans like copays and coinsurance. These costs vary by plan.
Individuals who live in areas with limited Part C options should consider purchasing a Medicare supplement plan instead.
Reinstating Medicare Advantage Plan Coverage
Plans with a Single Grace Period may disenroll individuals who miss one or more premium payments.
Plans that have a Rollover Grace Period allow their members to stay enrolled if they owe more than one month’s premium but pay for at least one premium during the grace period. If this occurs, a new grace period will begin.
Insurance companies will send notifications to members who have failed to pay their premiums, but will disenroll any member who fails to make a payment during the grace period.
Once an individual has been disenrolled from a plan, they will have to submit an application for coverage.
