What Is Medicare Part C Coverage?

Are you someone eager to learn more about Medicare coverage? Whether your interest stems from a need for coverage for yourself, a spouse, or a family member, it is a wise idea to learn as much as you can about it. However, as soon as you start to delve into the question of “what is Medicare?” it is likely you will feel confused..

Why? There are a lot of terms used and they are often mistakenly interchanged or misunderstood. For example:

  • Parts and Plans – There are Medicare Parts, such as the subject of this article – Part C. There are also Medicare supplemental plans, and they also are delineated using the alphabetic characters A-N.
  • Coverages – When trying to get an answer to the question of what is Medicare, or what is a specific type of Medicare plan, you’ll find out that there is hospital coverage, medical coverage, prescription drug coverage, Medicare Supplement Insurance (Medigap), and more
  • Other Medicare – There is also the issue of “other” insurance, and this can include Medicare Cost Plans, Demonstration/Pilot programs, and PACE (Program of All-inclusive Care for the Elderly)

So, as you begin to navigate your way towards an answer about “what is Medicare Part C,” just know that this term should not be allowed to confuse you too greatly. It is easier to understand once you know the facts. Let’s start with the basics, though, because you cannot really comprehend Medicare Part C without also understanding Parts A and B.

Medicare 101

So, just what is Medicare, in a general sense? Medicare itself explains:

“Medicare is the federal health insurance program for:

  • People who are 65 or older
  • Certain younger people with disabilities
  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)”

They then clarify further by saying that there are different segments or Parts of Medicare and these help to pay for specific services.

They include:

  • Part A – This is hospital insurance that pays for inpatient care, hospice care, treatment in skilled nursing facilities, and some home health care
  • Part B – This is medical insurance that covers doctors’ services, medical supplies, preventative services, and outpatient care

Most people qualify for premium-free Medicare Part A but, some will have to pay for it. You pay monthly premiums for Medicare Part B coverage.

When you reach the letter “C” though, it is typically skipped, and the topic refocuses on Part D, which is prescription drug coverage. Why? Because Medicare Part C is actually Medicare Advantage.

Just What is Medicare Part C?

Medicare.gov has a great deal to say about the Medicare Advantage Plans (Part C.) They say that Medicare Part C is a “type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits. Medicare Advantage Plans include:

  • Health Maintenance Organizations
  • Preferred Provider Organizations
  • Private Fee-for-Service Plans
  • Special Needs Plans
  • Medicare Medical Savings Account Plans

If you’re enrolled in a Medicare Advantage Plan:

  • Most Medicare services are covered through the plan
  • Medicare services aren’t paid for by Original Medicare”

Most Medicare Advantage plans also include prescription drug coverage.

Enrolling in a Medicare Advantage Plan

Not all of the Medicare Advantage plans are going to operate identically, and it is important to take the time to find out all of the details of any Medicare Advantage Plan.

Typically, they vary from:

  • Health Maintenance Organization (HMO) Plans
  • Preferred Provider Organization (PPO) Plans
  • Private Fee-for-Service (PFFS) Plans
  • Special Needs Plans (SNPs)
  • HMO Point of Service (HMOPOS) Plans: An HMO Plan that may allow you to get some services out-of-network for a higher cost.
  • Medical Savings Account (MSA) Plans: A plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year.

There may be some criteria you should meet before you can enroll in any of the Medicare Advantage Plans you discover. For example:

  • You must have Medicare Parts A and B in place
  • You cannot have End-Stage Renal Disease
  • You must live in the Service Area of the plan

So, we now know the answer to what is Medicare Part C, or a Medicare Advantage Plan. We’ve discovered how they play out and what is needed before you can enroll in one. That means we should take some time to learn how they operate.

How Does a Medicare Advantage Plan (Part C) Work?

What is a Medicare Advantage Plan designed to do? It is, as we noted, the all in one option that combines both Medicare Part A and Part B. It is not identical to Original Medicare (Parts A and B chosen separately). The one key differentiator is that they are provided by private companies approved by Medicare. When you sign up for a Medicare Advantage plan, you’ll still have Medicare, and most often it will be more than just Part A & Part B. These plans usually include Medicare Part D –prescription drug coverage.

In addition to the types of standard Medicare coverage enjoyed in Parts A and B, the Part C option may enable the holder of the coverage to get extra benefits that Original Medicare does not offer like hearing, vision and dental. Most also use different rules and Medicare will typically pay only a fixed amount for your medical care to the insurance providers making the Medicare Advantage Plans available. They can charge different out of pocket costs.

For example, you might need referrals, you may be obliged to go to specific facilities for care, and changes in coverage may happen on an annual basis. They typically bundle the prescription drug coverage. You will be disenrolled from your Medicare Advantage Plan and returned to original Medicare if you are in a Medicare Advantage HMO or PPO and you enroll in a separate Medicare Prescription Drug Plan.

Can you combine Medicare Advantage Plans with Medigap policies? In a word: No. Medigap policies can’t work with Medicare Advantage Plans. If you have a Medigap policy and enroll in a Medicare advantage Plan (Part C), you may want to drop your Medigap policy because it can’t be used to pay your Medicare Advantage Plan copayments, deductibles and premiums.

When looking for accurate answers to what is Medicare Advantage coverage, you need to understand that it is a bundle and that it can have pros or cons depending upon your needs. It can help reduce out of pocket expenses and even enable out of network coverage. However, it does have some limitations.

What is the Medicare Enrollment Period for Part C Options?

Medicare Advantage plans also have specific enrollment requirements, and the following applies:

  • Initial Enrollment Period or IEP – This is the first time you can sign up for Medicare and may opt for Parts A-D at that time. This is a seven-month window that includes three months prior to the 65th birthday, the month of the birthday and three months afterward. Coverage begins no earlier than the birthday month.
  • Medicare Advantage Open Enrollment Period (OEP) –The Medicare Advantage Open Enrollment Period goes from January 1 through March 31 every year. You can switch from an existing Medicare Advantage plan to a different one or drop your Medicare Advantage plan and return to Original Medicare (Part A and Part B).
  • Special Enrollment Period or SEP – This applies if you delay enrollment in Parts A-D and will only be effective if you have coverage from an employer; OR within the eight months after coverage via Parts A and B end; OR 63 days after coverage ends for Parts C and D

Fall Open Enrollment – This is frequently called the Annual Election Period and begins on October 15 each year and ends December 7. During this window, you can switch to a Medicare Advantage plan (Part C) from Original Medicare (Part A & Part B); You can do the reverse and go back to Original Medicare from a Medicare Advantage plan (Part C); you can drop or switch to a Medicare Prescription Drug Plan (Part D) if you have Parts A & B; and you can switch from one Medicare Advantage Plan to another. Coverage begins January 1 of the following year. Now that you have more answers to the question of: “what is Medicare Part C?” take some time to shop around and find the plan that best fits your needs and budget and you will find it to be a valuable experience.

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