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Part C - Overview

Instead of enrolling in Medicare Parts A and B, you may go for Part C, called Medicare Advantage (MA), and combine it with a Prescription Drug Plan. Part C coverage includes services under both Part A and Part B and often includes additional benefits as well. Many Part C plans also combine prescription drug coverage. Here is a brief overview of Medicare Advantage plans.

Part C - Overview

PART C (Medicare Advantage) - Overview

There are two primary ways you can get Medicare coverage. One is to go with Medicare Parts A & B and supplement it with a Medicare Supplement (Medigap) Plan and/or a Prescription Drug Plan. The other option is to go for Part C, called Medicare Advantage, and combine it with a Prescription Drug Plan. You cannot combine Part C with Medicare Parts A/B or with Medicare Supplement.

Part C includes coverage provided by both Part A and Part B (you will continue paying Part B premiums). These plans are offered by private carriers. Many Part C plans also include additional benefits. However, you may be limited to the plan’s network of doctors and hospitals.

Coverage

Medicare Advantage plans not only cover almost all the services that Medicare provides through both Part A and Part B but may also offer extra benefits such as vision, hearing and dental coverage and other health and wellness programs. They may charge an extra premium for these additional services. There may be other opt-in services as well.

Several Medicare Advantage Plans now include Prescription Drug coverage as well and are sometimes abbreviated as MA-PD plans. These plans offer an "all-in-one" option for those who do not want to shop around for different plans. However, make sure that the prescription drug coverage offered meets your needs.

Types of MA Plans

Private insurance companies offer many different types of MA Plans as summarized below. Their network and cost may vary by type, carrier, coverage and service area.

MA Plan Type

Highlights

HMO (Health Maintenance Organization)

  • Limited to plan’s network of doctors and hospitals
  • You usually pay full amount for services outside the network
  • Need to pick a Primary Care Physician (PCP), who oversees all healthcare needs

 

HMO Point of Service (HMO-POS)

  • Same as HMO plans, except that out-of-network services can be availed of for a higher copay/ coinsurance

 

PPO (Preferred Provider Organization)

  • Preference for plan’s network of doctors and hospitals
  • You may go outside the network but may pay a higher copay/ coinsurance than if you had stayed within the network
  • There may be no need to choose physicians up front to manage health care

PFFS (Private Fee-for-Service)

  • Payment terms are set by the carriers
  • You may go to any healthcare provider who accepts the plan's terms, fees and conditions
  • If there is no drug coverage, you can join a stand-alone Part D plan

SNPs (Special Needs Plans)

  • For those who have chronic diseases, are institutionalized or have Medicaid
  • Prescription drug coverage is included

 

MSA (Medical Savings Account)

  • High-deductible Plans
  • Like a Health Savings Account (HSA), MSAs link a Medical Savings Account with the High-deductible Plan
  • Medicare deposits some money into the account through your Plan, which you may use to meet your deductible and other costs
  • Prescription drug coverage is not included

 

 

MA Plans with Prescription Drug Coverage

Many HMO and PPO Plans include coverage for prescription drugs and are called MA-PD plans. These are an "all-in-one" option for Medicare enrollees.

Out-of-pocket Costs

You may have to pay a monthly premium for Medicare Advantage plans in addition to having to keep paying the Part B premium. Behind the scenes, Medicare pays a fixed amount for your Part A and Part B coverage to the companies offering MA Plans. The additional premium charged for Part C, if any, is mostly for extra coverage like prescription drugs, dental, vision, hearing, and wellness programs.

Apart from the monthly premium, if any, your out-of-pocket expenses may include deductibles, copays/coinsurance, higher cost sharing if you go out of the network, and costs for opt-in benefits which are sometimes offered by MA plans. 

One of the major benefits of a Medicare Advantage plan over Medicare Parts A & B is that there is a limit on your out-of-pocket costs. Once you reach this limit, you pay nothing for covered services. For 2020, this Maximum Out of Pocket (MOOP) limit on expenses for services covered under Parts A and B is $6,700 per year for in-network providers. Plans may offer a lower MOOP limit but cannot exceed this maximum.

Enrollment

To enroll in MA Plans, you must be eligible for Medicare Part A and enrolled in Part B. If you have ESRD, then you may only enroll in Special Needs Plans (SNPs) meant for those with renal disease. However, if you are already enrolled in an MA Plan and then develop ESRD, you cannot be disenrolled by the Plan.

Initial Enrollment Period (IEP): You can enroll in MA Plans when you first become eligible for Medicare and sign up during your Initial Enrollment Period (IEP) which starts three months before the month you turn 65 and runs for three months after, for a total duration of 7 months.

General Enrollment Period (GEP): If you completed enrollment into Parts A & B during the GEP (January 1st to March 31st), you may enroll in a Medicare Advantage plan during April 1st to June 30th of that year. 

Annual Election Period (AEP): If you have Medicare, you can join, switch, or drop an MA Plan between October 15th and December 7th of each year. Your coverage will begin on January 1st of next year. Between January 1st and February 14th, you may leave the MA Plan and go back to Medicare Parts A & B.

Medicare Advantage Open Enrollment Period (MA OEP): Starting 2019, the earlier MA Disenrollment Period stands replaced with the MA OEP which runs Jan 1st - Mar 31st every year. During this period you may switch your Medicare Advantage Plan, with or without prescription drug coverage, or opt for Medicare Part A and Part B.

Special Enrollment Period (SEP): Under specific situations, you may be eligible for a Special Enrollment Period e.g. if you move out of your plan's service area, you enroll into or leave Medicaid, you qualify for Extra Help, or if you live in an institution. There are other situations as well which may qualify you for a SEP. During the SEP you may be able to join or switch an MA plan.

Keep in mind that you may lose your prescription drug coverage if you change from an MA-PD plan to an MA Plan that does not include prescription drug coverage. In that case, you may have to wait until the next Annual Election Period to get drug coverage and may be assessed a late enrollment penalty. 

                                                                                                                                                  

Click here to learn more about Medicare, its various Parts, different enrollment periods and your costs. 

We have also created videos to help you better understand various topics related to Medicare. Select and watch a video explaining the topic of your interest in a simple and intuitive manner.

Remember that you cannot choose just any combination of Parts and Plans. Let Lighted Road Insurance guide you step-by-step through the Medicare ecosystem and help you in selecting the right plan(s) for your needs. 

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This website (LightedRoadInsurance.com) contains information about and access to insurance plans for eligible and soon to be eligible Medicare beneficiaries and their advisors. It is operated by Lighted Road Insurance Services, an agency affiliated with HealthCompare Insurance Services Inc., a licensed health insurance agency to sell Medicare products.

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Last Updated: 11-17-2019