Medicare Part C
Medicare Part C is more commonly known as a Medicare Advantage.  It is viewed as the plan that provides some value added benefits that may not be available through Original Medicare. 

Part C is not a program that you enroll in at your local Social Security office.  Similarly, you do not enroll into Medicare Part D or a Medicare Supplement plan there as well. At the Social Security website or at one of their offices you are only enrolling into Original Medicare Part A and Part B. 

Medicare Part C plans provide you an alternative to Original Medicare that you would coupled with a Medigap plan or Medicare Supplement plan. Medicare Advantage plans are optional, and and they should be considered once you have reviewed all of your available options.  
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Medicare Part C Plans

Similar to obtain a Medicare Supplement policy from a private health insurance company a Medicare Part C plans is also provided by private health insurance companies.  However, when you sign up for a Medicare Advantage plan you are leaving Original Medicare and turning over your health insurance to be managed by the private insurance company.   

Medicare Advantage plans bundle everything together Part A, Part B and usually Part D coverage all under a single plan which is administered by an Insurance Carrier and their group of networks (HMO).

Instead of using your Original Medicare card, you will have a separate medical ID card issued by the Insurance Carrier you selected that you will use at hospital, doctor’s office and pharmacy. Most Medicare Advantage plans include Part D drug plan, although in some areas you can find them without Part D coverage included.  These plans that exclude Part D are typically for US Veterans who have creditable Part D coverage through the VA Hospital.

Medicare Advantage plans resemble traditional group insurance or individual insurance benefits you may have had prior to being eligible for Medicare. Clients will typically request that they stay with the same Carrier they had prior so they do not lose their Doctors.  While it is possible that your Doctors could still be covered with the same insurance carrier, we have found in many instances for this to not be the case. 

Medicare Advantage plans are primarily HMO products that require you to be enrolled into a specific network of Doctors and Hospitals.  Depending on your location plans may require you to pay a monthly premium, copays for many routine services like doctor’s visits, lab-work, ambulance, surgeries, hospital stays, urgent care and more.  While in other areas of the Country like Southern California many plans come at no additional premium and zero dollar copays.  

What does Medicare Advantage
Plans / Part C Cost?

Medicare Advantage / Part C plans generally speaking come with lower monthly premiums or no monthly premium. There are several reasons why Medicare Advantage plans are treated differently

By joining a Medicare Advantage plan, you are agreeing to be treated in the plan’s limited network of providers and they are designed as a pay as you go plan.  If you leave the network of providers assuming it is not an emergency, you would be responsible for 100% of the bill. 

As these plans are typically HMO network, you would be assigned to what the insurance industry calls a Gatekeeper or as you know them your primary care physician.  Your primary care Doctor’s job is to help manage your care and provide you with a referral when needed.  They also help facilitate obtain prior approvals from your Network for a needed surgery.

Depending on your location there might be an option to obtain a Medicare PPO plan or Medicare PFFS options.  Typically, if you desired a PPO plan option we would recommend you stay with Original Medicare and obtain a Medigap plan.  This is because a Medicare Advantage plan that offers the PPO option come at a very high cost.   

One of the big attractions for Medicare beneficiaries to obtain a Medicare Advantage plans is due to their zero dollar premium plan options.  This does not mean that Medicare Advantage plan is free. Remember these plans are a pay as you use them type of plan.  They can have some sizable max out of pocket cost and some pretty narrow networks. 

You might be asking, how do the Medicare Advantage Carriers get paid if I have no monthly premium and a small copay.  When you enroll in a Medicare Advantage plan, the US Government pays a fixed monthly sum (around $1,000 per month depending on their Star Rating) to the insurance carrier for the private insurance carrier to manage your care. Because they are being subsidised by the government they are able to offer you premiums as low as zero dollars to attract you to their plan.

Unlike Original Medicare with a Medigap plan, your Medicare Advantage plan can and will change from your to year.  This includes your Part D coverage that is included as part of your Medicare Advantage plan.  It is important that you review all layers of your plan on an annual basis.

Medicare Advantage Out-of-Pocket Maximums

All Medicare Part C plan are required to have an max out-of-pocket (“MOOP”) maximum to protect you from a catastrophic event. Each Medicare insurance carrier will adjust this Max out of pocket limit depending on your local area and local competition.  They are prohibitive from going higher than the approved amount but they can offer a lower amount. Each year Medicare established the highest allowable amount for your MOOP maximum each year.

For 2021 the Medicare Advantage plans the MOOP is $7550 for coverage that are included under Medicare Part A and Medicare Part B. While this is a very large number and can add up to some pretty significant bills the good news is thankfully there is a cap to those medical bills.  Under Original Medicare with NO Medigap plan you have an unlimited liability exposure. 

Even though your Medicare Advantage plan includes your Part D coverage this does not mean that your MOOP for Part A and Part B are tethered together.  Your Part D has a seperate MOOP that you will need to be concerned with.  

As part of your annual review of available Medicare Advantage plans one of the items you should look at is the MOOP maximum on that plan. One bad health year can add up to some significant cost to you and quickly deplete your savings account.  While the MOOP is only one item to focus on it is a significant one for many people.  

If you are reviewing all of your plan options for the first time and are about to age into Medicare, this is the best time to make sure you are comparing not only a Medicare Advantage plan but also reviewing and considering Original Medicare with a Medigap plan.  If you are looking for flexibility, freedom, and security, Original Medicare with a Medigap policy can remove all of your max out of pocket concerns depending on which plan you select.  These plans do have a monthly premium but they also allow you to fully budget for the unexpected.  

Medicare Part C Eligibility Requirements

One of the big attractions of the Medicare Advantage plan is it does not have a pre-existing conditions clause.  This mean you can move from one Advantage plan to the next.  Before you can join a Medicare Advantage plan you will need to do the following:

  • You are required to be enrolled in both Medicare Part A and Medicare Part B at all times.  
  • Live in the plan’s service area. 
  • Finally, starting in 2021 the restriction of not having End-Stage Renal Disease has been removed.  These individuals can now join any Medicare Advantage plan this is available in their local service area.

Medicare Advantage plans have specific election periods eligibility requirements that are different than a Medicare Supplement plan for those individuals who stay on original Medicare.

When you turn 65 you qualify for the Initial Enrollment Period which last a total of 7 months. During this time you have the ability to sign up for Medicare Part A and Part B.  During this same time you can select to either stay with original Medicare and purchase a Medigap plan or leave Original Medicare and join a Medicare Advantage plan.

on an annual basis you enter into a new eligibility requirement During this time you can make changes to your Medicare Advantage plan during a time known as the Annual Election Period (AEP) from October 15 to December 7 of each year.

This is available to you as your current Medicare Advantage plan may have made changes that you believe negatively affects you and/or their may be a better plan option available to you. 

There are also certain Special Election Periods (SEPs) that can be triggered in certain circumstances. A SEP can be activated if you move out of state and lose your plan base on specific guidelines. If you have a qualifying event, you could be allowed a SEP to enroll into a new plan mid-year.

What Does Medicare
Part C Cover?

When you think of a Medicare Advantage plan it covers the same things that are covered under your Part A and B services that you get from Original Medicare. However, there are some differences in how the coverage responds.  For instance under Original Medicare your Doctor decides what is medically necessary verses when you are enrolled in a Medicare Advantage plan the plans network and insurance carrier makes that decision.  

It is important to review annually each Medicare Advantage summary of benefits.  The summary of benefits is a great tool for your to review to see how your current plan compares to all available plans in your service area.  The summary of benefits will outline all cost associated with using the plan.  For instance it will show you how much you will pay for your Primary Care office visit, or an ER visit.  It will also tell you if you have dental or vision coverage as part of your plan.

Medicare Part C coverage typically provide you with a Part D drug plan. Which ever plan you select you are only given a single Part D option.  It is important to ensure your prescription drugs are covered by the Medicare Advantage plan you select.  When Part D drug coverage is provided through the Advantage plan you are not able to enroll in a stand alone Drug plan.  

Medicare Part C Enrollment Periods

For Medicare Advantage plans an easy way to remember when the annual enrollment period is nearing is when you see pumpkins showing up in front of houses or being sold in stores.

The annual election period happens each fall and ends just before the beginning of winter.  It runs from October 15 – December 7th of each year.  Any changes made go during this time go into effective starting on January 1st of the new year.  It no changes are made your current plan will automatically renew.

The annual election period exists because Medicare Advantage carriers are able to make big and small changes to their plans year year.  Some of these changes include formulary changes, pharmacy network, provider network, premium and/or co-payments, max out of pocket limits, dental, vision, and co-insurance. By creating this annual evaluation period you can do your best to ensure you have the best coverage in place from year to year.  

One of our Medicare insurance agent who specializes in Medicare-related insurance products can help you learn the enrollment periods available.

Do you need help with your Medicare Advantage Plan?

Medicare Advantage plans are a great insurance option that should be considered as part of your overall research.  Working with a licensed Medicare insurance agent will help you understand everything before you apply for a plan.  In addition there may be a plan that is more suited for your needs that you might not be aware of.

Do you need assistance in choosing the right plan that will be accepted by your doctor’s and provide affordable benefits to you? We are happy to help – call (562) 735-3553 x1 today!