Medicare Part C

Intro

Advantage, otherwise known as Part C, Medicare Private Health Plan, or Managed Care Plan, and previously known as Medicare + Choice, is the Medicare component of Medicare relating to private health insurance.

 

In this section, you can get Medicare benefits through your private health insurance company; the Government authorizes to offer such coverage.

 

They require any Medicare Advantage Plan to be like Original Medicare (Part A and Part B) but may do so with distinct rules, charges, and limitations on coverage.

 

Individual MAPDs (Medicare Advantage Prescription Drug Plans) include Part D of medication/ drug coverage under their benefits package.

 

To join a Medicare Advantage Plan, you must have Medicare Part A and Part B.

Medicare Advantage Plans include:

  • HMOs (Health Maintenance Organizations)
  • PPOs (Preferred Provider Organizations)
  • PFFS (Private Fee-for-Service) plans
  • SNPs (Special Needs Plans)
  • MSAs (Medical Savings Accounts)

 

You may also find they offer a POS (Point-of-Service) option.

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Part C Medicare Costs

Before opting for a Part C (Private Medicare Advantage or MA) healthcare plan, it is essential to determine which costs you may have to pay.

These costs may include the following:

 

Part C Medicare Premiums

For 2019, the projected average monthly premium of the MA plan is $28, although this can vary dramatically from plan to plan, from $0 to more than $200.

 

Remember that to join a Medicare Advantage plan; you will need A & B Medicare parts.

 

Payment of your regular premium for Part B will be made besides a premium required by the plan. However, in some MA plans, they may pay a percentage of your Part B premium. You will need to check with your plan to confirm this.

 

Part C Medicare Deductibles

There are only a few Medicare Advantage plans which have an annual deductible over and above the standard Part B deductible.

 

Plans providing coverage for prescription drugs may require a different deductible for drug coverage.

 

Co-payments

Co-payments will be made for particular services, like visits to a doctor. Co-payments are typically flat-rate fees in dollars, as opposed to the coinsurance percentage of traditional Medicare. Certain types of schemes demand higher co-payments to see healthcare providers beyond your network.

 

Annually, such plans define the sums they collect for premiums, deductibles, and services. Each Part-C plan may charge different amounts for expenses and may have additional regulations for the way you receive benefits. For example, you may need a referral to see a specialist, or you may only need to go to doctors, facilities, or providers who are part of the plan for non-emergency or non-emergency care.

 

While these rules are subject to change every year, the amount you pay can only change once a year, on January 1st. For existing Medicare beneficiaries, the cap on out-of-pocket spending in 2019 is a maximum of $6,700.

 

If you use independent providers, the limit may be higher. Several plans provide an out-of-pocket limit below the maximum of $6,700.

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SNPs are Part C plans which will only accept people from Medicare who:

  • Suffer from specific serious chronic diseases
  • Individuals who have cover by Medicaid and Medicare
  • People who live in selected nursing homes
  • People living at home and have high long-term nursing requirements may qualify for a nursing home.

When you have Medicare and Medicaid, they will cover most of your costs.

However, assuming you do not have Medicaid or receive assistance from other programs (like Medicare savings programs), you may have costs comparable to the fees you usually incur in a regular Medicare Advantage plan.

With Original Medicare, they will generally pay any hospital in-patient care by Medicare Part A.

Part C Medicare coverage includes the same services as Part A Medicare, including:

  • Hospital in-patient care
  • Skilled nursing facility in-patient care

Part C Medicare also covers:

  • Home health care

Part C of Medicare may have a different cost-sharing rate for in-patient and home care from the original Medicare.

With Original Medicare, Medicare Part B will usually cover out-patient care.

Out-patient care comprises medically necessary services and preventative treatments to avert or detect diseases. Part C of Medicare includes the same benefits as Part B of Medicare, including:

  • Doctor visits (primary care doctor and professional specialists)
  • Lab testing and X-rays
  • Preventative tests and vaccines, such as flu shots
  • Emergency Ambulance services
  • Both in-patient and out-patient mental health services
  • Durable medical equipment such as walkers and wheelchairs
  • Physical and Occupational therapy
  • Speech and language pathology

 

Part C of Medicare can include different sharing of out-patient costs than original Medicare.

As opposed to Original Medicare, Part C Medicare usually provides coverage for prescription drugs you are taking at home.

They list the precise prescription medication covered in the plan formulary; however, you will find such forms vary from one plan to another.

Other benefits that may be included in Part C of Medicare are:

  • Routine dental care and cleaning, x-rays and dentures
  • Routine eye care products such as contact lenses and glasses
  • Routine hearing screening services, including hearing aids
  • Health and Fitness benefits including exercise classes

 

When checking, you may find some Medicare Part C plans do not provide the same level of coverage for additional benefits.

For instance, some Part C Medicare plans may only provide “Medicare-covered dental benefits,” which are usually only covered for emergency accidental dental treatment or jaw disease.

If your Medicare Part C plan provides more dental coverage, you may experience a larger monthly premium for such coverage.

When you are refused cover for something you require, the first thing you can do is file an appeal.

You may appeal for a health care service, supply item, or prescription medication which you believe you should receive, or which you have already received.

You can also file an appeal against paying a lesser amount than they originally asked you to pay.

Should your appeal be denied or experience other frustrations regarding your plan, you may switch over to another Medicare Advantage program throughout the open enrollment period, which lasts from October 15th to December 7th each year.