What is Medicare Part C or Medicare Advantage?

Medicare Part C, also known  as Medicare Advantage is a “for profit” private health insurance plan that contracts with the government to provide healthcare for  its covered enrollees.

Medicare  Part C Advantage plans must cover all the same services as offered through Original Medicare Parts A and B. In addition, they may also provide additional services not included in Original Medicare . These services may include:

  • Refraction Eye exams and eyeglasses
  • Hearing exams and hearing aides
  • Routine dental care
  • Gym memberships
  • Over-the-counter benefit allowance
Many Medicare Advantage plans come with $0.00 or very low monthly premiums. Pricing will vary by plan provider. Medicare Advantage plans may charge different out-of-pocket costs and typically have deductibles and co-payments for covered services. 
 
Unlike Original Medicare, Medicare Part C Advantage plans have a maximum annual cap on out-of-pocket costs. The government has set $6700 as the most a plan may charge but many plans choose to make this number lower. Providers compete to make their plans more attractive than the competition and adjusting the maximum out-of-pocket amount they charge to a lesser amount is a significant means of attracting enrollees.
 
Note: This maximum out-of-pocket figure applies only to the medical portion of the Medicare Advantage plan. Out-of-pocket deductibles, copayments, and coinsurance related to the drug coverage portion of the plan are not counted in this figure.

 

Types of Medicare Advantage Plan Service Providers

What are the Requirements to Join a Medicare Part C Advantage Plan?

To be able to join a plan, you must.

  • Live in the plan’s service area (usually a county designation)
  • Have Original Medicare coverage, Parts A and B
  • Be a U.S citizen or lawfully present in the United States
  • Not have End-Stage Renal Disease (ESRD)

When Can I Enroll in Medicare Part C?

Enrollment in a Medicare Part C Advantage plan (such as an HMO or a PPO) is restricted to the following periods:

  • During the 7-month Initial Enrollment Period (IEP) when you first turn 65
  • During the 7-month period that begins 3 months before the 25th month of receiving Social Security or RRB disability benefits, that includes your 25th month of getting disability benefits, and that ends 3 months after your 25th month of receiving disability benefits
  • Between April 1 and June 30 if you have Medicare Part A and enrolled in Medicare Part B for the first time during the Part B General Enrollment Period (GEP) which runs from January 1 to March 31.
  • During the Annual Enrollment Period (AEP) which runs each year from October 15 to December 7 (During this period, anyone with Medicare can join, switch, or drop a Medicare Advantage Plan. Coverage for enrollment during AEP begins on January 1 as long as your plan receives your enrollment by midnight, December 7

Generally, once you are enrolled in a Medicare Part C Advantage Plan, you must keep that coverage for the calendar year. There are, however, special circumstances that would create a Special Enrollment Period (SEP) during which you can join, switch, or drop an Advantage Plan. Some of these circumstances are:

  • If you move out of you plan’s service area
  • If you have Medicaid in addition to Medicare
  • If you qualify for Extra Help
  • If you live in an institution
  • If your plan leaves Medicare or no longer provides coverage in your area
 

How Does Medicare Part C Coordinate With Other Coverage?

If you have health care coverage through an employer or union, you should speak with your benefits administrator before joining a Medicare Advantage plan. In some cases, this might cause you to lose your employer or union coverage not only for yourself but also for your spouse and dependents. However, there are cases where you may still be able to keep your employer or union health care coverage and use it along with your Medicare Advantage Plan. It is important to note that if you drop your employer or union coverage, you may not be able to get it back.

If you are enrolled in a Medicare Advantage Plan, you may not be sold a Medicare Supplement Insurance Policy except during the Annual Election Period when the new Medicare Supplement is set to begin on January 1 after your current Medicare Advantage Plan ends on December 31. If you have a Medicare Supplement Insurance Policy and enroll in a Medicare Advantage Plan, you will need to cancel the Supplement Policy because you may not have them both at the same time. A Medicare Supplement Policy can not be used to pay the deductible, copayments, or coinsurance of a Medicare Advantage Plan. However, because obtaining a Supplement Policy outside of your Initial Open Enrollment Period is contingent upon underwriting, if you cancel it, you may not be able to get it back.

How Much Will a Medicare Part C Advantage Plan Cost Me?

In order to be eligible to purchase a Medicare Part C Advantage Plan, you must first have Medicare Part B which carries a monthly premium. In addition, each plan may have a premium, a deductible, and may charge copayments and coinsurance. These costs will vary from plan to plan. Unlike Original Medicare, which has no maximum out-of-pocket (MOOP) limit, Advantage Plans generally have established MOOPs that generally range from $3000 to the Medicare maximum allowable amount in 2020 of $6700.

One other consideration is that the Maximum-Out-Of-Pocket (MOOP) resets every January. Where this could potentially be a problem would be if you had begun treatment for an issue such as cancer close to the end of the year. This could quickly cause you to meet the MOOP for that year. Then, if your treatment carried over into the new year, you would be responsible for meeting in once again. In this situation, you could have two amounts of up to $6700 back-to-back.

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