Medicare Part C: Understanding Medicare Advantage

Understanding Medicare can be daunting. Ahead, we explore Medicare Part C, including coverage, eligibility, enrollment, cost management strategies, and how to leverage Part C to your advantage. 

Related articles: 

• Medicare Part A: Understanding Hospital Insurance
• Medicare Part B: Understanding Medical Insurance
• Medicare Part D: Understanding Medicare Drug Coverage

What is Medicare Part C?

Medicare has four parts. Part A covers inpatient care, such as hospital stays, while Part B focuses on outpatient services. Part C, also called Medicare Advantage, offers an alternative approach.

Introduced in the 1970s, Part C was designed to provide beneficiaries with more choices and potentially lower costs within the Medicare framework. It has since grown in popularity, with numerous plan options catering to diverse caregiving needs and preferences.

Medicare Advantage acts as a one-stop shop, bundling the benefits of Part A (hospital insurance) and Part B (medical insurance) into a single plan delivered by private insurance companies approved by Medicare.

Many Part C plans also include prescription drug coverage (Part D), eliminating the need for separate enrollment.

Coverage under Medicare Advantage

Medicare Part C, or Medicare Advantage, is an alternative to Original Medicare (Part A and Part B) offered by private insurance companies approved by Medicare. It bundles the benefits of Medicare Part A and Part B, often includes additional benefits, and may also offer prescription drug coverage.

Essential benefits covered

Medicare Part C plans are required to provide at least the same level of coverage as Original Medicare. This means that all Medicare Advantage plans must cover:

• Hospital stays (inpatient care): This includes semi-private rooms, meals, general nursing, and drugs as part of your inpatient treatment. It also covers care in acute-care hospitals, critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals.
• Skilled nursing facility care: Coverage for skilled nursing facility care is provided under certain conditions for a limited time (generally up to 100 days).
• Home health care: Medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, and continued occupational services.
• Hospice care: Medicare Part A, not Part C, provided coverage, even if you have a Medicare Advantage plan.
• Doctor visits (outpatient care): Visits to primary care physicians and specialists, preventive services, outpatient surgery, and lab tests.
• Preventive services: Screenings, vaccines, and other preventive measures to help you avoid illnesses or detect health problems early.

Additional benefits available

One of the major advantages of Medicare Part C is that it often provides additional benefits not covered under Original Medicare. These can include:

• Vision care: Routine eye exams, glasses, or contact lenses.
• Hearing care: Routine hearing exams and hearing aids.
• Dental care: Routine dental exams, cleanings, x-rays, and sometimes more extensive dental procedures.
• Fitness programs: Memberships to fitness centers or discounts on exercise classes.
• Transportation services: Transportation to medical appointments.
• Over-the-counter (OTC) items: Allowances for certain OTC drugs and other health-related items.

Prescription drug coverage

Many Medicare Part C plans, known as Medicare Advantage Prescription Drug (MAPD) plans, include Medicare Part D prescription drug coverage. This means these plans cover most outpatient prescription drugs, including:

• Generic Drugs: Typically, these are the least expensive and are covered under the plan's formulary (list of covered drugs).
• Brand-Name Drugs: Higher-tiered medications that are often more costly than generics but are still covered under the plan's formulary.
• Specialty Drugs: High-cost drugs that may be used to treat complex or rare conditions. These often require special handling or administration.

Each Medicare Advantage plan's formulary can vary, so it's important to check if your medications are covered when selecting a plan. These plans also often include different tiers of coverage with varying copayment or coinsurance amounts.

Costs associated with Medicare Advantage

Unlike Part A (with no premium for most beneficiaries) and Part B (with a standard monthly premium), Part C plans have varying costs depending on the specific plan chosen, your location, and your income. These costs typically include:

• Monthly premium: The fixed amount you pay the insurance company for your Part C coverage.
• Deductibles: Amount you pay out-of-pocket before the plan starts covering benefits.
• Copayments: Fixed dollar amounts you pay for specific covered services.
• Coinsurance: A percentage shared with the insurance company for some covered services.

How to enroll in a Medicare Advantage plan

Enrolling in a Medicare Advantage plan (Medicare Part C) involves understanding the eligibility requirements, specific enrollment periods, and following the correct enrollment process.

Eligibility requirements

To enroll in a Medicare Advantage plan, you must meet the following criteria:

• Medicare Parts A and B enrollment: You must be enrolled in Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
• Residence: You must live in the service area of the Medicare Advantage plan you wish to join. Each plan covers a specific geographic area, which can vary from county to county.
• End-stage renal disease (ESRD): Generally, you cannot join a Medicare Advantage plan if you have ESRD, except in certain situations, such as joining a Special Needs Plan (SNP) that serves individuals with ESRD.

Enrollment periods

There are specific periods during which you can enroll in or switch Medicare Advantage plans:

• Initial Enrollment Period (IEP): This is a seven-month period that starts three months before the month you turn 65, includes your birth month, and ends three months after your birth month. If you qualify for Medicare due to a disability, your IEP is the seven-month period surrounding your 25th month of disability benefits.
• Annual Election Period (AEP): The Open Enrollment Period runs from October 15 to December 7 each year. You can join, switch, or drop a Medicare Advantage plan during this time. Coverage will begin on January 1 of the following year.
• Medicare Advantage Open Enrollment Period: From January 1 to March 31 each year, if you're already enrolled in a Medicare Advantage plan, you can switch to a different Medicare Advantage plan or go back to Original Medicare. This period does not allow for the addition of Part D if you switch back to Original Medicare.
• Special Enrollment Period (SEP): Certain life events can qualify you for an SEP, allowing you to enroll in or change your plan outside the usual enrollment periods. Examples include moving out of your plan's service area, losing other health coverage, or qualifying for Extra Help with Medicare prescription drug costs.

Enrollment Process

The process to enroll in a Medicare Advantage plan involves the following steps:

1. Compare plans: Use the Medicare Plan Finder tool on the Medicare website (www.medicare.gov) to compare your area's available Medicare Advantage plans. Consider factors like premiums, coverage, out-of-pocket costs, and additional benefits.
2. Review plan details: Carefully review the details of the plans you're interested in, including the provider network, covered services, and prescription drug formulary, if applicable. Ensure the plan meets your healthcare needs and budget.
3. Enroll in a plan: You can enroll in a Medicare Advantage plan in several ways:
   • Online: Visit the Medicare website and use the Plan Finder tool to enroll.
   • By phone: Call the plan provider directly or call Medicare at 1-800-MEDICARE (1-800-633-4227).
   • Paper enrollment form: Complete a paper enrollment form from the plan you want to join and mail it to the provider.
   • Via insurance agent or broker: You can also get assistance from a licensed insurance agent or broker who can help you understand your options and complete the enrollment process.
4. Confirmation: After enrolling, you will receive a confirmation letter from your selected Medicare Advantage plan. Keep this letter for your records. Your new plan coverage will begin on the effective date specified, typically January 1 for those enrolling during the AEP.

Types of Medicare Advantage Plans

Medicare Advantage plans come in several types, each offering different levels of flexibility, coverage, and costs. Here are the main types of plans available:

Health Maintenance Organizations (HMOs)

HMO plans require a network of doctors, hospitals, and other healthcare providers. You'll need a referral from your primary care physician to see a specialist. These plans often have lower premiums and out-of-pocket costs but less flexibility in choosing healthcare providers.

Preferred Provider Organization (PPO)

PPO plans offer more flexibility by allowing you to see any healthcare provider, but you'll pay less if you use providers within the plan's network. You don't need a referral to see a specialist; these plans typically have higher premiums than HMOs.

Private Fee-for-Service (PFFS)

PFFS plans allow you to see any Medicare-approved doctor or hospital that accepts the plan's payment terms. You have more freedom to choose your providers, but costs can vary, and not all providers may accept the plan.

Special Needs Plans (SNP)

SNPs are designed for individuals with specific diseases or characteristics, such as chronic illnesses, living in a nursing home, or being dual-eligible for Medicare and Medicaid. These plans tailor their benefits, provider choices, and drug formularies to meet the specific needs of the groups they serve.

Differences between Medicare Advantage and Original Medicare

When deciding between Medicare Advantage (Part C) and Original Medicare (Part A and Part B), it's important to understand the key differences to make an informed choice for your healthcare needs.

Original Medicare (Part A & Part B)

Original Medicare offers greater flexibility in choosing any doctor or hospital that accepts Medicare. However, it may require managing separate bills from Part A and Part B providers and potentially enrolling in a separate Part D plan for prescription drug coverage.

Considerations:

• Coverage and cost-sharing: Original Medicare typically covers 80% of approved healthcare costs, with beneficiaries responsible for the remaining 20%. There is no out-of-pocket maximum, so that costs can add up significantly, especially for extensive medical care.
• Doctor network and referrals: You can see any doctor or specialist who accepts Medicare without needing referrals. This provides more freedom to choose healthcare providers.
• Flexibility and mobility: Original Medicare is accepted nationwide, making it ideal for those who travel frequently or live in multiple locations throughout the year.
• Prescription drug coverage: You need to enroll in a separate Medicare Part D plan for prescription drug coverage.

Medicare Advantage (Part C)

Private insurance companies offer Medicare Advantage plans and bundle Medicare Part A and Part B benefits, often including additional benefits and prescription drug coverage.

Considerations:

• Network coverage: Medicare Advantage plans typically have specific networks of doctors, hospitals, and other healthcare providers. Confirm that your relative's preferred doctors and specialists are included in the plan's network.
• Drug coverage: Many Medicare Advantage plans include Medicare Part D prescription drug coverage. Choose a plan that covers current medications and consider future needs.
• Out-of-pocket costs: Compare monthly premiums, deductibles, copays, and coinsurance for different plans. Medicare Advantage plans often have an annual out-of-pocket maximum, providing a cap on how much you spend each year.
• Additional benefits: Medicare Advantage plans often offer extra benefits not covered by Original Medicare, such as vision, dental, hearing, and transportation services. Consider these additional benefits that might be valuable for your relative.
• Doctor network and referrals: Some Medicare Advantage plans require you use a network of doctors and get referrals for specialists. This can limit your choice of providers but may result in lower out-of-pocket costs.
• Flexibility and mobility: Coverage is typically limited to a specific geographic area, disadvantaging those who travel frequently or live in multiple locations. However, emergency and urgent care services are covered anywhere in the U.S.

Family caregivers: Leveraging the power of Part C

Medicare Part C is a popular healthcare option that bundles hospital and medical insurance into a comprehensive plan. This plan can include extra benefits like prescription and dental, eye care, and hearing care. Anyone eligible for traditional Medicare can enroll in a Part C plan during the Open or Special Enrollment Periods. 

Medicare Part C offers the convenience of having all your healthcare services bundled together in one plan while potentially saving money on additional benefits. Don't miss out on exploring your healthcare options and finding a plan that fits your needs. Make informed decisions for your loved one's health and confidently navigate the Medicare maze.