Medicare Part C - Medicare Advantage

The main parts of Medicare are broken down into lettered pieces. Medicare Part A is your hospital coverage, Medicare Part B is your outpatient coverage, and Medicare Part D is your prescription drug coverage. What about Medicare Part C? This part of Medicare is a bit different.

When you enroll in Medicare you are given two options to supplement your coverage. You can either choose to stay with Original Medicare and enroll into a Medicare Supplement plan and a Part D Prescription Drug Plan, or you can choose a Medicare Part C plan, also known as a Medicare Advantage Plan.Medicare Advantage Medicare Advantage plans are alternative insurance that take you away from Original Medicare, and put you into a plan with a private insurance carrier. Essentially, these plans are a difference form of your Medicare coverage. It’s helpful to keep in mind that Medicare C isn’t for everyone and that it’s best to weigh your options to find out which one will fit perfectly for your healthcare needs.

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Medicare Advantage Plans

What are Medicare Advantage Plans?

These are plans that will pay for your healthcare instead of Medicare. Consider looking at Medicare C as a combo deal of Parts A, B, and D all in one. With this part, you’ll have the ID card that you’ll use wherever you need healthcare. Many of these plans will have a Medicare Part D that is integrated within the plan. However, these may be absent in some areas, so make sure you look over those details as prescription drugs are expensive.

These plans are typically structured as HMO, or sometimes PPO plans. Therefore, many of these plans offer benefits similar to what you’d find through your former employer’s health insurance plan. Usually, you’ll deal with a local network and will have copays for ordinary things like:

  • Doctor’s visits
  • Lab work
  • Ambulance rides
  • Surgeries
  • Hospital stays
  • Urgent care and other services

Medicare Advantage Cost

Are Medicare Advantage plans free?

Unfortunately, healthcare does have a cost to it. Medicare is often viewed as a pay-now or pay-as-you-go system. With a Medicare Advantage plan, you often have the benefit of lower monthly premiums. Some plans may even have $0 premiums! Sounds great, right? Don’t be fooled, these plans are not free plans. After enrolling in a plan, Medicare will pay a specific amount to the insurance provider with a fixed sum. Many companies will offer lower premiums in hopes you’ll sign up for the plan they offer. Remember, costs will change yearly. The expenses that change will be for your monthly premiums, any of your copays, the drug formulary, and any of the benefits you receive through the plan.

Although the low to zero dollar premium sounds exciting, one aspect you really want to pay attention to on Medicare Advantage plans is the out-of-pocket maximum.

With each plan, there is an out-of-pocket maximum (OOP) that the plan must have. This OOP is set by Medicare and is the highest amount allowable each year. For Part C, this amount is $6,700 in 2020, and $7550 in 2021. Remember that all your Part D spending does not contribute to this out-of-pocket maximum amount. The OOP is going to be the most you will spend in the year for your Part A and Part B charges. 

When it comes time to look at the different plans and parts of Medicare, take a look at Part C’s OOP maximum. Please consider whether or not you’ve had a bad year in your health, especially if there were lots of copays and coinsurance costs related to your health care. Check to see if you have enough saved up to meet this OOP maximum. If not, you may want to continue looking at other more cost-efficient options.

Your Spending on Medicare Part C

  • You will continue to pay your Part B monthly premium.
  • You’ll also pay a monthly premium to your insurance company for your Part C plan.
  • You may be responsible for a deductible. If so, this must be paid before the plan’s benefits kick in.
  • Most medical services and treatment will require you to pay a copay or coinsurance.
  • It is possible that many services will require coinsurance up to 20%.
  • Your out-of-pocket maximum can be as high as $6,700 in 2020 or $7,550 in 2021.

Keep in mind that some of these costs will vary from plan to plan and don’t include any Part D spending. It’s best to check your plan’s benefit summary to see your annual OOP and what expenses you’ll be required to pay.

Medicare Advantage Networks

You are probably wondering, “what doctor’s accept Medicare Advantage Plans?”

One of the most significant differences between Original Medicare with a Medicare Supplement Plan and a Medicare Advantage plan is the use of networks. Medicare Advantage plans have specific networks of providers based on the plan you enroll into. You’ll also be responsible for your copays as these will be out-of-pocket.Unhappy Camper These networks are usually HMO. This means that you may have to choose a physician and get referrals within that network.

However, you may find options like PFFS and PPO. Many of these have benefits for out of network care, but typically for an additional. On top of your premium that you’ll pay monthly, you’ll have to worry about copays, deductibles, and any coinsurance needed for any of the plan’s maximum out-of-pocket expenses.

Not only do you need to stay in network with these plans, you often times need pre-authorization from your plan for certain services. It is important to remember that there are steps in place to set up services and new providers under these types of plans.

This is the main reason I don't generally recommend Medicare Advantage plans. They limit your choice for doctors and hospitals. Staying on allows you to choose any doctor or hospital in the U.S. that accepts Medicare.
Keith Armbrecht
Medicare on Video

Medicare Advantage vs. Original Medicare

Is there a difference between Original Medicare and Medicare Advantage Plans? There is, and it helps to know what these are so you can make a better decision based on your health care.

With Original Medicare, you are still utilizing Medicare as your primary insurance, rather than transferring your coverage over to a private insurance company. This means that you can utilize any doctor in the country who accepts Medicare. That’s right, there are no networks! Further, you do not need referrals or pre-authorization for services, your service just has to fall under Medicare’s two categories of services: medically necessary or preventative.

Unlike the Medicare Advantage plans, there is no maximum out-of-pocket with Original Medicare. This means you are responsible for all deductibles and coinsurances with no stop. Fortunately, there are plans like Medicare Supplement plans that will cover the majority of these costs to you with an affordable premium. 

Give us a call at 877-88KEITH (53484), an experienced agent will be able to review the premiums in your area for the available Medicare Supplement plan options. 

Medicare Advantage Plan Eligibility

Now the biggest question on your mind is whether or not you’re able to get a Medicare Advantage plan? No matter your age, if you are a beneficiary of Medicare, then you can buy a plan. It would help if you met some of the criteria, though.

  • You have to have enrolled in Part A and Part B. If you enroll in a Medicare Advantage plan, you must keep Part B as dropping it will see you dropped from your Part C plan.
  • Whatever address you have with Social Security is also where your Medicare Advantage plan will be centered around. So, you must live in the area where your plan is servicing. This means the same county. Keep in mind that some plans will cover one or two of your state’s counties while some may cover the whole state.

There are election periods for Part C. This gives you two enrollment periods. These are the fall’s Annual Election Period and the Initial Enrollment Period. Depending on your circumstances, you may be eligible for a Special Election Period. An example is moving out of state and losing your plan.

Your Coverage with Medicare Advantage

Medicare Advantage plans will cover the same services that Parts A and B of Original Medicare will cover. This means that you can take advantage of all the inpatient and outpatient services and benefits available.

The pro is that you won’t have to pay any deductibles or 20% of any medical services that you may need. However, the con is that you’ll be responsible for any copays that are part of your plan.

Each plan will have a benefits summary. This will also list the medical services that you’ll be covered for. It will also show any copays you’ll be responsible for and coinsurance. Usually, the highest amount you may see for an in-network service will be 20%.

It is important to review your benefit summary to get an idea of what you may be responsible for paying for any services or items that you may need. Everything that you pay for any services that are Part A and Part B will go to your OOP maximum. After that, Medicare Advantage will pay 100% for the rest of the year. Some Part C plans may also have Part D drug plans integrated into them, as this may help you when it comes to paying for your prescription fees. It is important to remember though, that your Part D spending does not contribute to your Part C maximum out-of-pocket.

Do I Have to Enroll in Part C of Medicare?

No, you need it as enrolling in it optional. You can choose Part C or enroll in Parts A and B instead. It is ultimately your choice of which one will be best for your health care needs. It is important to weigh the benefits of Original Medicare with a Medicare Supplement plan vs a Medicare Advantage plan against each other.

When to Enroll in Medicare Part C

When it comes to the enrollment periods for Medicare Advantage plans, you’re limited to certain periods for any enrollment or dis-enrollment. You have the Initial Enrollment Period that comes with Part B.Sign Up for Medicare You’ll also have the option of the Annual Election Period that comes each fall. The dates for the AEP are October 15th through December 7th. Your benefits will kick in on January 1st of the following year.

Because of the changes that a provider may make on a yearly basis, the Annual Enrollment Period is offered as a way for you to change to any other plans. Things that change will be your benefits, network pharmacy, formulary, premiums, copays, and coinsurance cost. This period of enrollment is for Parts C and D only, and if allowed by Medicare in case, the upcoming changes aren’t to your liking.

Outside of these two enrollment periods, there are some exceptions that will give you a Special Enrollment Period. This can be due to a change in employer group insurance or if you have made a move that is outside your plan area. Ask your insurance agent on what enrollment periods are available for you. That way, you can stay covered.

Part C Help

When it comes to any plans for Medicare Advantage, they will have certain rules, enrollment periods, and networks. There will also be limitations, restrictions on services and areas, and even copays that may apply to your coverage. If you have questions, working with a licensed Medicare agent will help gain a clear understanding of Part C before you apply for a plan.

When it comes to Medicare, there are many options to help you with your healthcare. You can choose to stick with the Original Medicare, opt-in to Medicare Advantage, or choose a Medigap Plan to fill the holes in your Original Medicare coverage. Your health is too vital to ignore. Having the right coverage will help you cut back on expenses and save money so you can enjoy life without the hassle of bills piling up on your table. Ask for help if needed, as navigating the Medicare landscape can be tricky for many people. 

Give us a call at 877-88KEITH (53484), an experienced agent will be able to review your options for you to help you make a decision on your Medicare enrollment. 

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