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Springfield, Missouri

Medicare Part C Eligibility

Senior men enjoying fishing as they discuss Medicare Part C eligibility.
Many Medicare beneficiaries are drawn to Part C plans because they have low premiums and additional benefits not found in Original Medicare or Medicare supplements.

Part C plans have become more popular over the last few years and are expected to increase in popularity. As a result, Medicare beneficiaries often ask about Part C eligibility and what benefits Part C plans provide.

What is Medicare Part C?

Part C consists of Medicare Advantage (MA) plans. MA plans are provided by private insurance companies who the government has approved to sell Part C plans. They must have at least as much coverage as Original Medicare (Parts A and B) but often offer extra benefits.

Many Medicare beneficiaries are drawn to Part C plans because they have low premiums and additional benefits not found in Original Medicare or Medicare supplements.

Who is eligible for Medicare Advantage plans?

Eligibility for Part C is the same as it is for Original Medicare. You are eligible to enroll in Medicare if you fall into one of these categories:

  • You are 65 years old or older
  • You have been on disability for two years
  • You have been diagnosed with End Stage Renal Disease

You must enroll in Medicare Parts A and B before applying for a Part C plan. In addition, you must continue to pay the Part B premium while enrolled in Part C. Failure to pay this premium will result in your plan’s termination.

You cannot have a Medicare Advantage plan and a Medicare supplement plan simultaneously. You can switch from a Medicare supplement to an MA plan, but you can only be enrolled in one or the other.

Senior woman enjoying time with her dog as she think about her Medicare Part C eligibility.
Part C plans have become more popular over the last few years and are expected to increase in popularity.

Types of Medicare Advantage Plans

There are five types of Medicare Advantage plans, and it is important to know the difference between each type of plan.

Health Maintenance Organizations (HMO)

HMOs are one of the most popular Medicare Advantage plans because they typically have the lowest premiums. You may even find HMO plans with a $0 monthly premium. (Keep in mind, there are other costs associated with Part C plans, so the $0 premium doesn’t mean the plan is free!)

HMO plans have a lower premium because they have strict rules on which providers you can see. If you have an HMO plan, you must see a physician who is contracted with your plan. If you go outside your plan’s network, you will have no coverage except for emergencies.

You’ll also need to designate a primary care physician (PCP) and get a referral from them if you need to see a specialist. The specialist must also be in the plan’s network.

Preferred Provider Organizations (PPO)

PPOs also utilize provider networks, but the networks are usually larger. Plus, you will have coverage if you receive care outside of the network – you may pay a larger share of the expense, though. PPO plan members will not need to choose a PCP and can see a specialist without a referral.

PPO premiums are usually higher than HMO premiums, but some beneficiaries want more freedom to choose their doctors and get care from other providers.

You can also enroll in an HMO-POS plan. POS stands for Point of Service. These plans are a mix of the first two types, which gives policyholders more flexibility.

Private Fee-for-Service Plans (PFFS)

PFFS plans are much different than HMOs and PPOs. They are not nearly as popular and aren’t even available in every state.

Insurance companies who offer PFFS plans pay contracted providers to offer their services to plan members. The insurance company also dictates how much their members must pay for services. Individuals with a PFFS plan can see any contracted provider. However, this can get tricky because providers can choose to stop accepting the payment terms at any time. This means that beneficiaries will need to check with their provider before each visit or risk paying the full fee for services. 

Medical Savings Account Plans (MSA)

If you are familiar with Health Savings Accounts (HSAs), you can easily understand how an MSA works. MSAs are high-deductible plans that require their members to pay the deductible before coverage begins. Once the deductible has been met, many MSA plans offer 100% coverage for services.

MSA policyholders will be issued a separate savings account and will usually be given a deposit at the start of each year. The deposit will never fully cover the deductible, but it will help the member pay for some expenses. Whatever amount is left in the account at the end of the year will be rolled over into the following year.

We’ve discussed four types of Advantage plans so far. We’re giving the last type of Advantage plan its very own section since its eligibility requirements differ from the others.

Medicare Advantage Special Needs Plans (SNP)

SNP plans are designed and tailored for Medicare beneficiaries with specific chronic conditions, diseases, or financial situations. To enroll in an SNP, you’ll need to meet certain eligibility requirements. There are several types of SNP plans, and the requirements for each one are different.

Some of the conditions that SNPs cater to include:

  • dementia
  • chronic heart failure
  • cardiovascular disorders
  • cancer
  • diabetes
  • chronic lung disorders
  • HIV/AIDS
  • ESRD requiring dialysis
  • autoimmune disorders
  • and several others

 

There are other SNPs designed for individuals living in long-term care facilities. In addition, individuals who are “dual-eligible,” meaning they are eligible for Medicare and Medicaid, also have an SNP tailored for them.

If you need help determining which Medicare plan you are eligible for, speak with one of our licensed insurance agents. We can review all of your Medicare options and help you find the one that fits your needs.

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