Medicare Part C (Medicare Advantage)Instead of using Original Medicare (Part A and Part B), you may decide to enroll yourself into Medicare Part C called today Medicare Advantage Plan. These plans are offered by private insurance companies, and must be approved by Medicare. It is not a ‘fee for service’ as in Original Medicare. Instead, Medicare pays a fixed amount every month to insurance companies for the enrolled members regardless whether the services were used by members.
ELIGIBILITYYou are eligible for Medicare Part C if:
- You have both Part A and Part B
- You live in the service area of the plan
- Plans must enroll anyone who is eligible. The same benefits are offered to all members, no matter what age or health status. Consequently, pre-existing health conditions cannot be taken into account: enrollment cannot be denied, and the premium cannot be increased because of the health conditions.
- Covers all services that Original Medicare covers (Part A and Part B), except hospice care. (Original Medicare covers hospice care even if you are in Medicare Advantage Plan).
- May offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs
- Can come as Medical only (MA) or may include Prescription Drug Coverage (MA-PD)
- There are several types of plan available: HMO, PPO, PFFS, MSA, and SNP
- Plans have different rules for how you get services. Most plans are HMO’s. You must stay “in-netowrk” and you must get referrals from your primary care physician. Emergencies are exceptions: no referrals are necessary, and services are available anywhere in the U.S.
- You are still a part of Medicare system. If the private insurance company fails, you are guaranteed the acceptance back into Original Medicare.
PREMIUM / DEDUCTIBLE / CO-PAYMENT / COINSURANCE
- Each plan typically charges a monthly premium in addition to the Part B premium (although, some plans actually pay the Part B premium). There are additional charges for Prescription Drug Coverage (if applicable), and for Extra coverage (if applicable). The total cost may be higher or lower than you’ll pay under Original Medicare.
- Each plan can charge different out-of-pocket costs. You normally pay co-payments for each visit or service. The plan may charge you yearly deductible or any additional deductibles.
- Medicare Advantage Plans will offer a maximum out-of-pocket yearly limit.
- Medicare places restriction as to when you can enter or leave (for another Medicare Plan) a Medicare Advantage. These restriction change on a yearly basis, but require changes be made during an enrollment Period.
ENROLLMENTYou can join, switch, or drop Medicare Advantage Plan:
- At Initial Enrollment Period – a 7-month period that begins 3 months before you turn 65, or 3 months before your 25th month of disability. The period includes the 3 months before, the month of, and the 3 months after the triggering event, such as ‘turn 65′.
- At Annual Enrollment Period – between October 15 and December 7. Your coverage will begin on January 1 of the following year. You may switch between Medicare Advantage plans. You also may switch from Medicare Advantage plan to Original Medicare, or from Original Medicare to Medicare Advantage plan. Be careful in considering joining Medical only plan (MA) from another plan (Medicare Advantage or Original Medicare) with Part D coverage – you’ll lose the existing Part D coverage. Also, if you are in MA-PD plan and you decide to join the standalone Medicare Prescription Drug Plan (PDP), you’ll be dis-enrolled from your MA-PD plan and return back to Original Medicare.
- At Medicare Advantage Disenrollment Period – between January 1 and February 14. You can dis-enroll from your current Medicare Advantage plan, but only return to Original Medicare. You can also select a PDP for Part D coverage.
- In certain situations you may be eligible for a Special Election Period (SEP) that allows you to make changes in your coverage outside of enrollment periods described above. Examples of SEP are: you’ve moved out of service area, you are qualified for an Extra Help, you have both Medicare and Medicaid, etc.
- People who either have Medicare and Medicaid or qualify for Extra Help can switch plans every month.
- Normally enrollment is on calendar year basis, starting the date your coverage begins.