What is Medicare Part C all about? Medicare Part C works similarly to Original Medicare, but some of the differences may work to your advantage. Read on to learn about the many features and benefits of Medicare Part C coverage and decide if it’s right for you.
What is Medicare Part C?
Medicare Part C, also called Medicare Advantage (MA), is 1 of the 4 Medicare parts: A, B, C, and D. Part C offers Medicare beneficiaries an alternative way to get Medicare benefits. Part C plans are sold by private insurance companies that contract with the Centers for Medicare & Medicaid Services (CMS). You’re still a part of the Medicare program when you enroll in Part C. Your Part A (hospital insurance) and Part B (medical insurance) are combined into one Medicare Advantage plan.* Medicare Advantage plans can also include extra benefits, such as dental care and Part D prescription drug coverage.
3 Highlights of Medicare Advantage
Although Medicare Advantage plans vary, overall, plans offer many advantages. Below are 3 highlights we like to call “The 3 Cs of Medicare Part C.”
- Convenience: Medicare Advantage offers a way to bundle your hospital, medical, prescription drug, and some supplemental health insurance benefits all under a single policy.
- Choice: You can choose a plan that has the supplemental benefits you want and get one with or without Part D drug coverage.
- Cap on out-of-pocket spending: Unlike Original Medicare, MA plans have a cap or limit on out-of-pocket costs for in-network Part A and B services**. After you’ve met the plan’s maximum out-of-pocket limit, the plan pays 100 percent of the cost for additional covered expenses. The maximum out-of-pocket limit is $6,700 per year, but CMS recommends that plans set a limit of $3,400 or less. The average out-of-pocket limit as of 2019 is $5,059.
What Does Medicare Part C Cover?
With the exception of hospice care, Medicare Part C plans cover all Part A and Part B benefits. Some plans include supplemental health benefits Original Medicare doesn’t cover. Most plans (90 percent as of 2019) come with prescription drug coverage, and those are known as Medicare Advantage Prescription Drug Plans (MA-PDs). You can also enroll in a standalone prescription drug plan (PDP) through a private, Medicare-approved insurance company to add drug benefits to certain Part C plans, such as a private-fee-for-service plan or a Medicare MSA plan. All Part C plans must provide coverage for emergency care outside the plan’s service area, but not outside the United States. Plans can also change benefits each year. Below, we provide an overview of covered benefits to help you learn more about Medicare Part C.
|Medicare Advantage Summary of Benefits|
|Part A Hospital Insurance||Part B Medical Insurance |
|Supplemental Health Benefits1|
1Benefits vary by plan.
|Part D Prescription Drug Benefits2|
2Each plan has a unique formulary of covered drugs.
Who Should Get Medicare Advantage?
Anyone who is eligible for Medicare Part C can enroll in a plan. But you may be an ideal candidate for a Medicare Advantage plan if you:
- Want to take advantage of low premiums. The average enrollee in an MA plan that includes drug coverage pays a monthly premium of $29. Premiums can be lower or higher depending on the county, the plan type, and other plan characteristics.
- Have experience with plans that use networks. You may be familiar with some of the different types of individual and family health insurance plans that use provider networks, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Plan options like these are also available with Medicare Advantage, and they work in a similar fashion.
- Live in a service area with strong network options. Some Medicare Advantage service areas have strong networks because there are more providers in that area who contract with plans to give enrollees access to care. Metro areas, for example, usually have more provider options, such as doctors, specialists, and hospitals.
- Don’t do a lot of extended travel. If you frequently travel to locations that are outside your MA plan’s service area or network and you need medical care, care received may not be covered (unless it’s an emergency), or it may cost you more to use an out-of-network provider.
- Prefer to have a copay rather than a coinsurance. MA plans, many of which are HMOs or PPOs, are more likely to have fixed copayments instead of a coinsurance. With a coinsurance, the amount you pay out of pocket depends on the total cost of covered services. Most covered services under Original Medicare have a 20 percent coinsurance.
Am I Eligible?
You must have both Medicare Parts A and B to be eligible for Part C. You must also live in a Medicare Advantage service area where private insurance companies offer plans. You usually can’t enroll in Part C if you have permanent kidney failure, known as end-stage renal disease (ESRD). But there are a few exceptions:
- If you were already enrolled in a plan and later developed ESRD, you may be able to keep your plan or switch to another with the same insurance company. If the company has cancelled its Medicare contract or downsized out of your service area, this gives you a one-time right or special enrollment period to join another MA plan.
- If you live in a service area that offers Special Needs Plans (SNPs) for people with ESRD, you may be able to join the plan.
- If you’re already enrolled in a health plan, such as an employer group health insurance plan for example, and the insurance company also sells MA plans, you may able to switch to an MA plan that the company offers.
- If you’re eligible for Medicare and you complete a successful kidney transplant, you may be able to enroll in an MA plan by submitting medical documents regarding the transplant.
When Can I Enroll?
You should know that you don’t have to enroll in Medicare Part C coverage. If you’re on Medicare and you choose not to enroll in Part C, you will continue to receive your Medicare Part A and/or Part B benefits, as well as any drug coverage you may have from a stand-alone drug plan. If you do decide to enroll in Medicare Advantage, there are different enrollment periods in which you may do so. These include specific dates during the year, when you turn 65, or when you are under 65 and have a disability. Below are 4 types of enrollment periods for Medicare Advantage plans.
- Initial Coverage Election Period (ICEP) Turning 65: You first become eligible to enroll in Medicare Advantage at the same time you become eligible for Medicare Parts A and B, when you’re turning or have turned 65. This is a 7-month period that includes the 3 months before the month of your 65th birthday, your birthday month, and the 3 months after your birthday month. This also applies if you already have Medicare because of a disability and are turning 65.
- ICEP Under 65: If you first became eligible for Medicare because you’re under 65 and have a disability, your Part C Medicare enrollment happens during the 7 months surrounding your 25th month of receiving disability benefits from Social Security or the Railroad Retirement Board. This includes the 3 months before your 25th month of disability benefits, the 25th month, and the 3 months after the 25th month.
- ICEP if You Only Got Part A When You Were First Eligible: If you already had Medicare Part A but didn’t get Part B until the Part B General Enrollment Period (January 1 to March 31), you can enroll in an MA plan with or without prescription drug benefits between April 1 and June 30.
- Medicare Annual Enrollment Period (AEP): AEP is when you can shop for Medicare plans, which includes switching from Original Medicare (Parts A and B) to a Medicare Advantage plan with or without Part D drug coverage. This period occurs annually from October 15 to December 7.
What is Medicare Part C Special Enrollment Period?
Certain life events trigger special enrollment periods (SEPs) when you can switch from one Part C plan to another or sign up for Medicare Part C coverage for the first time. There are several life events that count as SEPs for Medicare Advantage. Many of these SEPs also apply to Medicare Part D prescription drug plans. Some of these SEPs include:
- Plan not renewing or reducing its service area: You can enroll in another MA plan starting December 8 and ending the last day of February. This SEP also applies to your “one-time right” to join a plan if you have ESRD.
- Medicare ending (terminating) the plan’s contract: You can switch to another MA plan starting the 2 months before the contract terminates and ending 1 full month after the contract terminates.
- Losing eligibility for Medicaid: If you receive a notice that you will no longer be eligible for Medicaid benefits for the current plan year, you will have 2 full months after receiving the notice to join an MA plan. If you will not be eligible for Medicaid the following year, you can enroll in an MA plan between January 1 and March 31 (the same dates for the Part B General Enrollment Period).
- Living in a Part C or Part D service area with an overall 5-star quality rating: You can join an MA plan (or a Part D or Medicare Cost plan) with an overall 5-star quality rating one time between December 8 and November 30.
Enrollment by the Numbers
An increasing number of Americans are enrolling in Medicare Advantage plans each year. If fact, enrollment has quadrupled from 5.3 million in 2004 to 22 million in 2019. As of 2019, Part C enrollees make up 34 percent of the near 65 million Medicare recipients. Enrollment in Medicare Part C plans is expected to see continued growth in future years. The chart below shows the projected growth of Medicare Advantage enrollment through 2026.
Note: Includes cost and demonstration plans, enrollees in Special Needs Plans, and other types of Medicare Advantage plans.
Source: Congressional Budget Office’s March 2016 Medicare Baseline, CMS Medicare Advantage enrollment files for 2008-2014, and Mathematical Policy Research’s “Tracking Medicare Health and Prescription Drug Plans Monthly Report” for 1992-2007.
Disenrolling From Medicare Advantage
Besides certain SEPs that allow you to disenroll from or drop your Medicare Advantage plan, there are 2 main times a year when you can drop your plan and return to Original Medicare:
- Medicare Annual Enrollment Period (AEP): The October 15 to December 7 AEP, also called the Medicare Open Enrollment Period, allows you to disenroll from Medicare Advantage and reenroll in Original Medicare with coverage effective January 1. During this time, you can also:
- Switch from your Part C plan to another
- Join, drop, or switch prescription drug plans
- Medicare Advantage Disenrollment Period: From January 1 to February 14, you can drop your Part C Medicare plan and return to Original Medicare with coverage starting the first day of the next month. If you choose to add prescription drug benefits to Original Medicare, you must do so by February 14 of that same year. It’s important to know that you cannot do any of the following during this time period:
- Switch from one MA plan to another
- Switch from one Part D drug plan to another
- Join, switch, or drop a Medicare Medical Savings Account (MSA) plan
Medicare Advantage Plan Types
Medicare Advantage HMO Plans: The majority of Part C plan members, which amounts to 62 percent as of 2019, are enrolled in Medicare Advantage HMO plans. Receiving care through an HMO is usually limited to in-network providers, unless you have a medical emergency or need urgent care and can’t get to an in-network provider. You usually need to get all your basic healthcare through your primary care physician (PCP) and need a referral from your PCP to see a specialist. Many plans also include Part D drug coverage. If you have such a plan, you can’t enroll in a stand-alone prescription drug plan (PDP).
Medicare Advantage PPO Plans: One of the main differences between HMO and PPO plans is that PPO plans are more flexible—you can go outside the plan’s network for care. But the downside to going out of network is that the plan covers less of your healthcare costs. You usually don’t need to choose a PCP or get a referral to see a specialist. Like HMO plans, Medicare Advantage PPO plans usually include drug coverage, and you can’t enroll in a PDP if your Part C plan already provides drug benefits. In learning more about what is Medicare Part C and its plan types, you should know that there are 2 types of Medicare Advantage PPO plans.
- Local PPOs: As of 2019, 31 percent of Part C enrollees are in local PPOs. Local PPOs (as well as HMOs—both of which are coordinated care plans) can pick which counties to serve upon approval from the Centers for Medicare & Medicaid Services (CMS). Plans can also have different premiums and benefits among counties.
- Regional PPOs: Regional PPOs are also coordinated care plans. And people with these plans make up 6 percent (as of 2019) of Medicare Advantage enrollees. Plans operate in 1 of the 26 Medicare Advantage regions mandated by the CMS. A region can be a single state or multiple states. Unlike local PPOs, benefits and premium rates for regional PPOs are the same for all regions the plan serves. Regional PPOs also have more network flexibility.
Special Needs Plans: SNPs are designed for Medicare beneficiaries who have specific medical conditions, a dual eligibility status, or a need for care in an institutional facility (also known as a residential facility). To help make sure enrollees have the proper care management, plans usually require they choose a PCP or care coordinator. There are 3 types of SNPs, with each having specific provider options, benefits, and drug formularies, as well as a requirement to include Medicare Part D drug coverage. Plan types vary by location, so some may not be available in certain U.S. regions or counties.
- Severe or Disabling Chronic Condition SNPs (C-SNPs): Only people with certain chronic medical conditions are eligible for C-SNPs. Conditions must meet one of these criteria.
- Be life threatening
- Be substantially disabling
- Carry a high risk of hospitalization
- Require specialized delivery systems
- Dual SNPs (D-SNPs): Most special needs plan members are enrolled in Dual SNPs. Dual here means you must have both Original Medicare (Parts A and B) and Medicaid to enroll. But plans can decide that only people in certain Medicaid categories are eligible. Choosing a PCP and getting a referral to see a specialist is often required with D-SNPs. Access to a care coordinator is also available with many plans.
- Institutional SNPs (I-SNPs): To be eligible for this type of Part C Medicare plan, you must need or be expected to need 90 or more days of care in an intermediate care facility (ICF), assisted living facility (ALF), long-term care skilled nursing facility (SNF), or other type of institutional nursing facility. Some plans, called “Institutional Equivalent SNPs,” provide coverage to eligible people who live at home (also referred to as living in the community) if the setting meets an institutional level of care.
Note: Another way you can get long-term care (LTC) benefits in facilities like the ones mentioned is to enroll in long-term care insurance. This is a type of supplemental insurance for seniors and younger individuals that can help protect your assets. Because LTC insurance is a supplemental health plan, Medicare Advantage eligibility requirements don’t apply. However, you usually can’t enroll if you’ve already been diagnosed with a disability or illness.
Private Fee-For-Service (PFFS) Plans: As of 2019, just 1 percent of people enrolled in Medicare Part C have a PFFS plan. PFFS plans allow you to visit any Medicare provider who is willing to accept the terms and conditions of the plan. Plans decide the amount you pay for care and how much they will pay providers. Plans can also decide whether or not to offer prescription drug coverage for seniors and younger people on Medicare. If no drug coverage is offered, you can join a stand-alone PDP. If the plan offers drug benefits, you must accept them, and you cannot enroll in a PDP.
HMO Point of Service (HMO/POS): This plan works like an HMO, but you have the flexibility to get certain medical care outside the plan’s network through the POS option. You have higher cost sharing when you go out of network, so your deductibles and coinsurances or copayments are usually higher than other types of plans. You usually need to file a reimbursement claim with the plan for services you paid for out of pocket.
Medicare Medical Savings Account (MSA)
This plan combines 2 parts: a high deductible health plan (HDHP) and a special type of savings account. You must meet the deductible before the plan starts to pay for covered services.
The savings account part is funded by the plan from money it receives from Medicare. You can use funds for covered Part A and Part B expenses, which count toward your deductible, or on expenses that are not covered. If you have additional medical costs and there’s no money left in the account, you pay for those costs out of pocket until the plan’s deductible is met. If there’s money left in the account at the end of the year, the money stays in the account, and you can use it on future medical expenses. Below are some other important things to know about Medicare MSAs:
- You can’t join a Medicare MSA if certain situations apply, such as being eligible for Medicaid.
- MSA plans don’t include prescription drug coverage—you would need to join a PDP to get drug benefits.
- Some plans include extra benefits, such as long-term care, vision, and dental coverage, for an additional cost.
- There are no networks—you can visit any provider in the U.S. who accepts Medicare.
- You don’t pay a monthly premium to your MSA plan, but you still continue to pay your Part B premium.
Tips on Choosing a Medicare Advantage Plan
- Assess your needs and budget. Example: Would you prefer a plan with in-network care to help save money on premiums?
- Compare plans in your area—benefits and premiums are different for each plan.
- Check whether healthcare providers you use are in the plan’s service area and network.
- Make sure your prescriptions are covered on the plan’s formulary if drug coverage is included.
- Understand how the plan works before you enroll.
- Speak with a licensed insurance agent to get more answers.
- Review your coverage each year to decide whether you want to change plans.
Read more Medicare tips for choosing a plan.
Medicare Advantage Plans by State
Medicare Advantage plans by state are typically divided by counties that represent a Medicare Advantage service area. Plans are available in most counties within the United States. A service area can also be divided into regions, as is the case with regional PPO plans. Regions can include one state or multiple states. According to a 2016 report from Kaiser Family Foundation, most states have a Medicare Advantage population of HMO enrollees, while 9 states have a population of mostly local PPO enrollees.
What Are Medicare Advantage Costs?
A key factor in understanding Medicare Part C costs is knowing that you still pay your Medicare Part B premium (directly to Medicare) in addition to the monthly premium (if any) for your Part C plan. The standard 2020 premium for Medicare Part B is $144.60. But if your Part B premium is paid through your Social Security benefit, your rate could be lower. If you’re eligible for a lower rate, Social Security will determine your exact Part B premium. On average, Part C premiums are typically lower than what you pay for Part B***.
Medicare Advantage premiums vary by plan type, geographic location, and other characteristics. And information on monthly premium rates is usually focused on Medicare Advantage Prescription Drug Plans (MA-PDs) because these are the vast majority of plans. Kaiser reports that “the average MA-PD enrollee paid a monthly premium of about $29 in 2019.” If you didn’t join an MA-PD, PDP, or other Medicare plan that offers Part D drug coverage when you were first eligible, you may pay a late enrollment penalty for Part D, which will be added to your monthly premium. But there’s no penalty if you get Extra Help or have other creditable drug coverage.
Below are more details on what Medicare Advantage costs for some of the different types of plans that include prescription drug benefits.
HMO: Since the Affordable Care Act (ACA) was passed in 2010, premiums for Medicare Advantage HMOs have decreased. The weighted average monthly premium for Medicare Advantage HMO plans in 2019 was $23.
Local PPO: Average premium rates have also decreased for local PPOs since the passing of the ACA. In 2019, the weighted average monthly premium was $39—down $9 from 2018.
Regional PPO: Average premiums for regional PPOs have decreased. The 2019 weighted average premium was $44—down $1 from 2018.
Medicare Advantage Zero-Premium Plans
Medicare Advantage plans can choose to pass on savings on healthcare costs to members, resulting in a $0 monthly premium. A plan can also be designed to not have a monthly premium, as is the case with a Medicare MSA. In understanding Medicare Part C and its costs, you should be aware that zero-premium Medicare Advantage plans are not free—you still pay your Part B premium as well as other Medicare out-of-pocket costs, such as deductibles.
The Kaiser Family Foundation reports that more than half of MA-PD enrollees (56%) have a zero-premium plan, with exception to their Part B premiums.
Other Facts to Know About Medicare Part C
Here is a list of other important facts you need to know about Medicare Part C plans:
- Because you’re still in the Medicare program, you have rights and protections.
- At any time during the year, providers can leave a Part C Medicare plan, and plans can change network providers.
- Part C plans are not allowed to charge more than Original Medicare does for certain services, such as skilled nursing facility care, dialysis, and chemotherapy.
- You can’t have prescription drug benefits through a Medicare Advantage (MA) plan and a stand-alone prescription drug plan (PDP) at the same time. If you’re enrolled in an MA plan with drug coverage and you enroll in a PDP, you will be disenrolled from your MA plan and reenrolled in Original Medicare.
- You can’t have Medicare Advantage and Medicare Supplement insurance If you want to join a Medicare Supplement plan, also called Medigap, you would need to make sure you can leave your MA plan before your Medigap coverage begins.
- If you’re enrolled in a Medicare MSA, an insurance company can’t legally sell you a Medigap policy.
We’ve covered a lot of information on Medicare Part C, so you may have an idea of what type of Medicare Part C plan may be the best fit for your needs. Ready to shop for a plan? Get started now by seeing quotes and enrolling online. Have more questions? Give us a call at (800) 488-7621 today. A licensed HealthMarkets insurance agent can help you make the right decision that could save you the most money. Our service is at no cost to you, and you’re never under any obligation to enroll.