Medicare Part C allows private insurance companies to sell health plans that provide Medicare benefits. Also known as Medicare Advantage, these plans are regulated by the Medicare program and can keep your medical, hospital and prescription drug needs (based on the plan) under one umbrella. But each plan can vary, so it’s important to make sure it provides the coverage you need before enrolling.
Are you searching for a new Medicare Part C plan? HealthMarkets is ready to help. Get started now to see quotes, compare plans and even enroll online.
Want to learn more about Medicare Advantage? This guide will break down some important considerations to keep in mind as you shop for a plan.
What’s the Difference Between Original Medicare and Medicare Advantage?
The main difference between Original Medicare and Medicare Advantage is that Original Medicare (Medicare Parts A and B) benefits are administered by the government, and Medicare Advantage (Medicare Part C) benefits are administered by private insurance companies.
Medicare Part A is known as hospital insurance. It covers services that are considered medically necessary to treat a disease or condition you may have.
In general, Part A can cover:
- Skilled nursing facility care
- Nursing home care: Skilled nursing facility
- Hospice and respite care
- Home health services: Physical therapy, speech-language pathology services
Medicare Part B is known as medical insurance. It covers medically necessary services needed to diagnose and treat a medical condition, and preventive services for common illnesses or help detecting these illnesses at an early stage.
Part B covers:
- Outpatient doctor visits
- Helps cover ambulance services, including emergency ground transportation, critical access hospital (CAH) and skilled nursing facility when you can’t be safely transported by car or taxi
- Durable medical equipment (DME), including canes, oxygen equipment and blood sugar monitors
- Mental health services, including inpatient, outpatient and partial hospitalization
- Second opinions before surgery to know and understand your treatment options
- Limited outpatient prescription drugs under limited conditions
Medicare Part D provides prescription drug coverage. Prescription Drug Plans can be purchased from private health insurance companies and added to Original Medicare. Each plan can vary the amount of coverage it gives to a unique list of covered drugs known as a formulary.
Medicare Advantage (Part C) plans are required to provide the same coverage as Original Medicare and many provide prescription drug coverage. For those looking for these benefits in addition to coverage not typically provided by Original Medicare, Medicare Advantage may be a great option.
To find more information about Medicare Advantage by state, choose your state from the list below:
The Cost of Medicare Advantage Plans
One highlight of Medicare Advantage is how it can help you save on both monthly premiums and out-of-pocket expenses when you receive care. However, how much you pay for your Medicare Part C plan can depend on a number of factors, including:
- Your plan’s monthly premium rate
- Your plan’s yearly deductible
- Your plan’s copay or coinsurance fees
- Your plan’s out-of-pocket maximum limit
- If your plan pays for your monthly Medicare Part B premium
- What type of service you need and how often you receive them
- If you’re seeing a provider that works within your plan’s network
- If you’re eligible for subsidies or government assistance
If your Medicare Advantage plan doesn’t cover your Part B premium, you may have to pay two separate premiums each month. However, this can still be a more affordable option than paying for Part A (if you don’t quality for “premium-free Part A”), B, and D individually.
In 2020, the average premium for a Medicare Advantage with prescription drug coverage is$36 per month (when not weighted by enrollment). Most of Medicare Advantage plans offer prescription drug coverage (90%)with more almost half (49%) charging no premium for their plan. They are only required to pay their Part B premium.
Contact a HealthMarkets agent today to see how much you can save with a Medicare Advantage plan.
Types of Medicare Advantage Plans
Since Medicare Part C plans are available through private health insurance companies, you have options for which type of plans you want to enroll in. These plans can determine which healthcare providers you visit and how much coverage you receive when you seek service from a doctor or specialist in or out of your plan’s network.
There are four types of plans from which you can choose:
- Health Maintenance Organization (HMO) plans
- Preferred Provider Organization (PPO) plans
- Private Fee-for-Service (PFFS) plans
- Special Needs Plans (SNPs)
A Medicare Advantage HMO plan requires you to use a specific network of doctors, hospitals and other providers in order to receive your benefits. A primary care physician coordinates your care and provides referrals to specialists when necessary.
These plans usually have lower out-of-pocket costs than PPO plans, and provide coverage for deductibles, a drug benefit plan or wellness programs.
Unlike an HMO plan, Medicare Advantage PPO plan doesn’t limit you to its network of providers. While you can see any doctor you want, it may cost more to see a doctor outside of the network. You also don’t need a referral from a primary care physician. These plans also often offer benefits not included with Original Medicare coverage, like dental and vision care
These plans usually place limits on out-of-pocket expenses on services like emergency and urgent care coverage and prescription drug coverage.
A Medicare SNP is a type of Medicare Advantage plan that limits membership to people with specific diseases or characteristics. The plan is uniquely tailored to their specific benefit needs, choice in providers, and needed drug formulary.
Typically, those enrolled in SNPs must get their health care from in-network doctors and specialists, except for emergency and urgent care. You are required to have a primary care doctor or care coordinator to help with your health care, and you must have a referral to see a specialist.
Depending on your own unique health and budget needs, there’s a type of Medicare Advantage plan that can work for you. Before enrolling, make sure that your plan has the coverage you need for your necessary medical services.
Are You Eligible for Medicare Advantage?
Now that you know about your Medicare Part C options, it’s important to make sure that you qualify for this type of coverage. Before you can even qualify for a Medicare Advantage plan, you must first be eligible for Medicare. Eligibility includes:
- Those age 65 years and older
- Those younger than 65 years who have certain disabilities
- Those with End-Stage Renal Disease (ESRD)
- Those with Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease)
However, not all Americans who are eligible and enrolled in Medicare may be qualified to join a Medicare Advantage plan. Qualifications for Part C can include:
- Enrollment in Medicare Parts A and B
- Living in the Medicare Advantage plan’s service area
- No diagnosis of ESRD
To learn more about your Medicare Advantage eligibility, contact a HealthMarkets agent today.
How to Enroll in Medicare Part C
If you qualify for a Medicare Advantage plan and are ready to enroll, it’s important to understand Medicare’s enrollment periods. While you may be automatically enrolled in Medicare when you become qualified, you must enroll in a Medicare Advantage plan.
You can enroll during specific times of the year, including:
- The Initial Enrollment Period when you first become eligible for Medicare
- The Annual Enrollment Period when you can change your current plan for a different one
- The Special Enrollment Period when specific circumstances occur, such as:
- Moving to a new location
- Becoming eligible for Medicaid
- Qualifying for Extra Help with Medicare prescription drug costs
- Getting care in an institution, such as skilled nursing facility or long-term hospital care
With the yearly changes affecting the cost of Medicare, it’s important to make sure you have the most up-to-date information about your benefits and coverage. You can get smart, unbiased help from HealthMarkets. You can get smart, unbiased help from HealthMarkets. Get started today!
“What Part A Covers — Medicare.gov.” 2015. | “What Part B covers — Medicare.gov.” 2015. | “What drug plans cover — Medicare.gov.” 2015. | “Costs for Medicare Advantage Plans — Medicare.gov.” 2015. | “Medicare Advantage 2015 Data Spotlight: Overview of Plan Changes — KFF.” 2014. | “Different types of Medicare Advantage Plans — Medicare.gov." | “Medicare Special Needs Plans (SNP) — Medicare.gov.” 2015. | “Original Medicare (Part A and B) Eligibility and Enrollment — CMS.” 2015. | “What’s a Medicare Advantage Plan? — Medicare.gov.” 2015. | “Understanding Medicare Part C & D Enrollment Periods — Medicare.gov.” 2015