Medicare Part C

Medicare Part C is a term for optional insurance plans. More often than not, they are now likely to be referred to as a “Medicare Advantage” plan.

Whether a plan is called Medicare Advantage or Medicare Part C, it refers to an insurance plan provided by private insurers, who are reimbursed partially by the U.S. Medicare program. These plans can bundle coverage provided by Medicare Parts A, B, and D. These components of Medicare provide hospital stay coverage, medical services coverage, and prescription drug coverage, respectively.

To be eligible for Medicare Part C coverage, you must be enrolled in both Medicare Part A and Part B. However, you will not be filing for your services, prescriptions or supplies under Original Medicare; be sure to use the provided Medicare Advantage card to ensure proper billing and coverage.

What does Medicare Part C cover? It can vary dramatically, which means there is no single, convenient Medicare Part C definition. Instead, you are provided with a host of options, many of which resemble non-Medicare plans provided by the average private health insurance carrier. 

Most Medicare Advantage plans bundle the aforementioned Part A and B coverage along with some prescription coverage similar to Medicare Part D. They may also include insurance for additional services, such as vision and dental. There are, of course, many exceptions as well as options for customization.

The only single unifying Medicare Part C definition is that the plans must meet the standards of the Centers for Medicare & Medicaid Services (CMS). This status also means that they are almost universally guaranteed to be accepted anywhere that accepts Original Medicare.

Beyond that, it’s most helpful to think of a Medicare Advantage plan as a bundled version of existing services that may or may not include additional coverage beyond the bare minimum Original Medicare offers.

Types of Medicare Part C Plans

Because a Medicare Part C plan is provided through a private insurer, it can resemble any number of other insurance plans commercially available. These include:

  • Private fee-for-service plans
  • Preferred provider organizations (PPO)
  • Health maintenance organizations (HMO)
  • Special needs plans
  • Medicare medical savings account (MSA) plans

It is important to emphasize again that Medicare Part C replaces your existing Part A and Part B coverage, which you must remain enrolled in to be eligible for Part C coverage. Not all Medicare Advantage/Part C plans provide prescription coverage which means you may need to be enrolled in a Part D plan, as well.

Be sure to closely review the eligibility criteria and coverage requirements for a Medicare Advantage plan you are considering. If you have any questions, want guidance, or require assistance, you can speak with an experienced health insurance professional here at MMIG.

How Are Medicare Part C Plans Different From Regular Insurance?

Medicare Part C plans have a number of advantages for those eligible to receive Medicare benefits. 

What are the Medicare Part C benefits? They include:

  • Rights and protections guaranteed to all Medicare recipients regarding the provision of care and access to certain types of services and supplies
  • Coverage of all services covered under Original Medicare
  • Negotiated pricing for all applicable services and supplies (excludes fees, deductibles, and cost-sharing)
  • Medicare Advantage plans are often provided at a lower cost than comparable non-Medicare plans since the carriers are often directly reimbursed in part by Original Medicare
  • You are eligible even with a pre-existing condition, although exceptions can apply to end-stage renal disease (ESRD)
  • Prescription drug coverage will closely mirror the policies and prices offered through Medicare Part D plans
  • You have the right to switch Advantage plans or go back to Original Medicare coverage if your plan decides to stop participating in the Medicare program

There are a few potential disadvantages to a Medicare Advantage plan, though, and the principal one is that you may be forced to visit doctors exclusively within your network. Doing otherwise could lead to uncovered costs, higher prices, or possibly even being dropped from your Medicare Advantage plan, under certain circumstances.

You also have to follow certain rules and policies to avoid paying a higher cost in many instances.

When Can You Enroll in Medicare Part C Plans?

There are two types of open enrollment periods for adding, dropping, switching, or modifying your Medicare Advantage plan.

The main Medicare Advantage open enrollment period goes from October 15 – December 7. During this time, you can switch from Original Medicare coverage to a Medicare Advantage plan, or vice-versa. You can also change from one Medicare Advantage plan to a different one, or modify your level of drug coverage if you already have it. Note that modifying drug coverage can affect your eligibility for Part C or Part D — more on that below.

You can also make certain modifications to your coverage during the standard Medicare open enrollment period from January 1 – March 31. During this time, you can switch from one Advantage plan to another, or disenroll from Part C altogether to return to Original Medicare coverage.

One exception to these periods is that you have the opportunity to change Medicare Advantage plans or go back to Original Medicare within the first three months that you receive coverage. This special period typically coincides with the first three months after your 65th birthday.

Special enrollment periods may be available for individuals who move out of their plan’s service area or have a sudden modification to their available coverage, so don’t hesitate to contact your local Social Security office or a health insurance professional if you have questions about modifying Part C coverage you are no longer eligible to receive.

How Medicare Part D Affects Part C

The relationship between Medicare Part D and Part C can be complicated. It can be summed up like this: you can’t enroll in a Part C plan with an HMO or PPO that has drug coverage if you already have a Medicare Prescription Drug Plan (Part D).

To reverse the statement: if your Medicare Advantage plan does not offer drug coverage, then you will be able to sign up for Part D coverage separately.

Medicare Part C Cost

All Medicare Part C plans will have different costs that will vary by region and the type of coverage they offer. To learn about the costs of an individual plan, you must research the plan’s policies and stated costs individually.

One thing worth noting again is that you must be enrolled in Medicare Part B to have a Part C plan, which can mean paying monthly premiums for Part B in addition to the costs of Part C.

With that said, there are a number of Medicare Advantage plans that have no premium. Some also cover the costs of your Medicare Part B premium.

Each Medicare Part C plan in Georgia will have different costs for premiums, copays, deductibles, and coinsurance amounts. Your costs may also differ depending on how often you go to the doctor and what services you tend to use. 

Extra benefits provided under the Part C plan will likely have their own set of costs.

In some instances, Medicaid can help pay for the cost of a Medicare Advantage plan.

Your plan is very likely to cost extra if you visit a provider who is out of network or otherwise violates the rules of your policy.

The silver lining is that many Medicare Advantage (Part C) plans have yearly out-of-pocket cost limits. Once these limits are reached, you are required to pay no additional costs aside from your premiums — although exceptions can apply.

Respective costs, including fees, premiums, and cost-sharing obligations are listed in the plan’s Evidence of Coverage (EOC) document provided to you. If you are on an existing plan and these figures change, then you are obligated to receive an Annual Notice of Change (ANOC) statement documenting the various differences.

Choosing the Best Coverage for Medicare Part C in Georgia

Unfortunately, the nature of Part C plans leaves a lot up in the air in terms of your final expected yearly costs and how much coverage you can hope to receive through your plan. The good news is that all of this variability means you have many options for selecting a Medicare Advantage plan in Georgia and customizing it to meet your needs.

To review the plans available to you and discuss which ones could provide the maximum benefit at the minimum cost, do not hesitate to contact us online or by phone at (678) 807-8414. Our offices can help you select the best plan for your unique health needs and personal preferences while also helping you with Protecting What’s Ahead.

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