Medicare Part C – In Detail

Part C Fast Facts:

Medicare Advantage Plans

  • Combines Part A and Part B, and with many plans, prescription drug coverage.
  • Offered by private insurance companies
  • Often includes additional benefits like vision, dental, wellness, nurse-line, and more.

Eligibility:

  • Must be enrolled in Medicare Part A and Medicare Part B
  • Must remain enrolled and pay premium due for Parts A and B
  • Must live in the service area of the plan. Plans are county specific.
  • Must NOT have end-stage renal disease (ESRD)
  • People with ESRD may be able to join a Medicare Special Needs Plan (SNP) if one is available in their area

Costs:

  • Premiums and terms/conditions of the plan can/will change from year to year
  • Year-to-Year contracts
  • Must continue to pay Part B Premium

Enrollment:

  • Eligibility is not affected by health or financial status, but there are election periods.
  • There are special rules for those with ESRD- Contact directly Medicare (800-Medicare) for assistance.

Coverage:

  • Convenience of a single plan which includes benefits for Parts A, B, and D
  • Coverage is limited to a service area- Network based- unless there is an emergency
  • May be required to use doctors and hospitals that are included in the plans network only.
  • May offer additional benefits not covered by Medicare like dental, vision, hearing, and preventive care.

Part C Strengths:

  • Convenience of single plan- One card for all benefits
  • Many may include Prescription Drug Coverage for no additional premium
  • Some plans may offer no or low monthly premium
  • May offer additional benefits no covered by Medicare A and B including but not limited to;
    • Dental
    • Vision
    • Preventive Care
    • Silver Sneakers/Gym Memberships
  • Eligibility for enrollment is not affected by health or financial status.

Part C Weaknesses:

  • With most MA and MA-PD plan options, coverage is limited to a service area.
  • Exceptions for emergencies
  • Access to doctors and hospitals may be restricted by network limitations
  • Plan premiums, benefits, and terms will change from year to year.
  • ANOC- Annual Notice Of Change Letters
  • Maximum Out-Of-Pocket for the year could be as high as $6,700 in Copayments and Coinsurance

Medicare Advantage- Part C : Enrollment & Disenrollment

  • You can join a Medicare Advantage Plan even if you have a pre‑existing condition, except for End-Stage Renal Disease (ESRD).
  • You can only join or leave a plan at certain times during the year.
  • Each year, Medicare Advantage Plans can choose to leave Medicare or make changes to the services they cover and what you pay. If the plan decides to stop participating in Medicare, you will have to join another Medicare health plan or return to Original Medicare.

Who Can Join?

To join a Medicare Advantage Plan you must meet these conditions:

  • You have Part A and Part B.
  • You live in the plan’s service area.
  • You don’t have End-Stage Renal Disease (ESRD)

When Can You Join?

Initial Enrollment Period (IEP, ICEP, IEP2)

  • You can sign up when you’re first eligible for Part A and/or Part B (for which you pay monthly premiums) during your Initial Enrollment Period. For example, if you’re eligible when you turn 65, you can sign up during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

Annual Enrollment Period / Open Enrollment Period (AEP/OEP)

  • Between October 15th and December 7th of each year, beneficiaries may change their Medicare Advantage, Medicare Advantage Prescription Drug, and Prescription Drug Plans to another plan with an effective date of January 1st of the following year.

This is the ONLY multiple election period. The last application in and processed is the application that will be in-force.

Types of Part C Plans

Coordinated Care Plans

  • Health Maintenance Organization (HMO) Plans
  • Preferred Provider Organization (PPO) Plans
  • Special Needs Plans (SNP) Plans
  • Health Maintenance Organization Point of Service (HMOPOS) Plans

Other Plans

  • Private Fee-For-Service (PFFS) Plans
  • Medical Savings Accounts (MSA) Plans – NOT AVAILABLE IN ALL STATES
  • Cost Plans

What is an HMO?

Health Maintenance Organization (HMO) Plans

  • Plan with a contracted network of physicians, hospitals, specialists and other health care providers
  • Primary Care Physician must be selected
  • Gatekeeper for care
  • May provide referrals
  • No out-of-network coverage
  • Emergencies are an exception
  • Many plans include prescription drug coverage and additional benefits
  • Often HMO plans are available with $0 Premium

What is a PPO?

Preferred Partner Organization (PPO) Plans

  • Plan with a contracted network of physicians, hospitals, specialists and other health care providers
  • Out-of-network coverage with higher out-of-pocket cost sharing
  • Offers more flexibility and choice for client
  • Usually has a premium
  • Many plans include prescription drug coverage and additional benefits
  • No referral needed to see a specialist

What is a SNP?

Special Needs Plan (SNP)

  • Designed for people with special or complex health care needs
  • Residents of nursing homes
  • People with certain chronic diseases such as diabetes or heart disease
  • NOT available in ALL States
  • People eligible for both Medicare and Medicaid
  • Includes prescription drug coverage and may also include additional benefits
  • Must be QMB or QMB+

What is a PFFS?

Private Fee-For-Service (PFFS) Plans

  • Plan with a contracted network of physicians, hospitals, specialists and other health care providers
  • Out-of-network coverage with higher out-of-pocket cost sharing
  • Offers a Maximum Out-Of-Pocket
  • Offers more flexibility and choice for client
  • Usually has a premium
  • Many plans include prescription drug coverage and additional benefits
  • No referral needed to see a specialist
  • Providers must accept terms and conditions of plan prior to each visit
  • As with Original Medicare, clients still have Medicare rights and protections, including the right to appeal.
  • Clients can check with the plan before receiving a service to find out if it’s covered and what out of pocket costs there may be.
  • You must follow plan rules, like getting a referral to see a specialist to avoid higher costs if your plan requires it. The specialist you’re referred to must also be in the plan’s network. Check with the plan.
  • If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher. In most cases, this applies to Medicare Advantage HMOs and PPOs.
  • If you join a clinical research study, some costs may be covered by your plan. Call your plan for more information.
  • Medicare Advantage Plans can’t charge more than Original Medicare for certain services, like chemotherapy, dialysis, and skilled nursing facility care.
  • Medicare Advantage Plans have a yearly cap on how much you pay for Part A and Part B services during the year. This yearly maximum out‑of-pocket amount can be different between Medicare Advantage Plans. You should consider this when

Prescription Drug Coverage

  • You usually get prescription drug coverage (Part D) through the plan. In some types of plans that don’t offer drug coverage, you can join a Medicare Prescription Drug Plan.
  • If you’re in a Medicare Advantage Plan that includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you will be dis-enrolled from your Medicare Advantage Plan and returned to Original Medicare.
  • You can’t have prescription drug coverage through both a Medicare Advantage Plan and a Medicare Prescription Drug Plan. You choose a plan.

If you have End-Stage Renal Disease (ESRD), you can only join a Medicare Advantage Plan in certain situations:

  • If you’re already in a Medicare Advantage Plan when you develop ESRD, you may be able to stay in your plan or join another plan offered by the same company.
  • If you have an employer or union health plan or other health coverage through a company that offers Medicare Advantage Plans, you may be able to join one of their Medicare Advantage Plans.
  • If you’ve had a successful kidney transplant, you may be able to join a Medicare Advantage Plan.
  • You may be able to join a Medicare Special Needs Plan (SNP) for people with ESRD if one is available in your area.

NO COST, NO OBLIGATION

Answers To Your Medicare Questions



Out-of-pocket costs in a Medicare Advantage Plan depends on the following:

  • Whether the plan charges a monthly premium.
  • Whether the plan pays any of your monthly Part B premium.
  • Whether the plan has a yearly deductible or any additional deductibles.
  • How much for each visit or service (copayments or coinsurance).
  • The type and frequency of health care services needed
  • Whether you go to a doctor or supplier who accepts assignment (if you’re in a Preferred Provider Organization, Private Fee‑for‑Service Plan, or Medical Savings Account Plan and you go out‑of‑network).
  • Whether you follow the plan’s rules, like using network providers.
  • Whether you need extra benefits and if the plan charges for it.
  • The plan’s yearly limit on out-of-pocket costs for all medical services.
  • Whether you have Medicaid or get help from the state.