Medicare Part C – Medicare Advantage

What is Medicare Part C or Medicare Advantage?

Medicare Part C, also known as Medicare Advantage, is a private health insurance plan that contracts with Medicare to provide health care for covered enrollees.
Medicare Advantages plans must cover all the same services as original Medicare Part A and Part B but they may also provide additional services not included in Original Medicare. These services may include:

  • Eye exams and eyeglasses
  • Hearing exams
  • Dental care
  • Gym memberships
  • Prescription drugs
  • Some foreign coverage

Many Medicare Advantage plans come with a $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-pays for covered services. These plans have an annual limit on a patient’s out-of-pocket costs for medical services but this limit may vary between providers. The maximum out-of-pocket cost allowed by CMS is $6700 for 2016. This figure does not include prescription costs or monthly premiums.

Medicare Advantage Plan Service Providers

Medicare Advantage organizations may be any of the following:


To Be Eligible to Join a Plan

  • You must live in the plan’s service area.
  • You must have Original Medicare coverage, Parts A and B
  • You may not have End-Stage Renal Disease (ESRD)
  • You must be a U.S. citizen or lawfully present in the United States


When to Enroll in Medicare Part C

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

  • During your 7 month Initial Enrollment Period (IEP) when you first turn 65
  • During the 7 month period starting 21 months and ending 28 months after you begin to get Social Security or Railroad Retirement Board benefits due to disability. Medicare coverage can begin 24 months after the beginning of SS or RRB benefits.
  • Between April 1 and June 30 if you have Medicare Part A and get 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 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 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 your plan’s service area
  • If you have Medicaid
  • 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

Coordination 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. 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.

What Will A Medicare 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 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 range from $3000 to the Medicare maximum allowable amount in 2016 of $6700.

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