Medicare Part C, also known as Medicare Advantage, combines the coverage of Medicare Part A and Medicare Part B into a single plan offered by private insurance companies. Beneficiaries who choose Medicare Part C receive their Medicare benefits through the Medicare Advantage plan.
What does Medicare Advantage cover?
Medicare Advantage (Medicare Part C) include everything Original Medicare does and often more.
Some medically necessary services offered by Medicare Advantage plans that are also covered by Original Medicare include:
- Clinical research
- Mental health
- Preventative services
- Durable medical equipment (DME)
- Hospital stays
- Skilled nursing facility care
Extra benefits within a Medicare Advantage prescription drug plan
Unlike Original Medicare, Medicare Advantage offers comprehensive coverage that includes additional benefits like prescription drug coverage . With Medicare Advantage, you may have the option to choose a Medicare Advantage prescription drug plan (MAPD) that combines your medical and prescription drug coverage, eliminating the need for a stand-alone Medicare Part D prescription drug plan. This integrated approach may simplify your healthcare management and may ensure that you have access to the medications you need. Medicare Advantage prescription drug plans can provide a convenient solution for individuals who want a single plan that covers both their medical and prescription drug expenses.
The approved prescription drugs will be listed in the plan you select, so be sure to confirm that your medications are covered before you enroll.
Medicare Advantage Plans may offer other extra perks too, such as:
- Fitness benefits: including gym memberships and exercise classes
- Routine dental care: including cleanings, X-rays, and dentures
- Routine vision care: including contacts and eyeglasses
- Routine hearing care: including hearing aids
Keep in mind, though, that not all Medicare Advantage plans cover extra benefits in the same way. For example, some Medicare Advantage plans might only cover “Medicare-covered dental benefits” — meaning dental care that’s needed for an accident or a disease of the jaw. If your Medicare Advantage plan covers dental benefits more extensively, you may have a higher monthly premium for that coverage.
What is the difference between Medicare Advantage and Original Medicare?
The main difference between Medicare Advantage and Original Medicare is how the coverage is structured and administered. Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance) provided directly by the federal government, while Medicare Advantage (Medicare Part C) is offered by private insurance companies approved by Medicare. Medicare Advantage plans often include additional benefits and may require the use of in-network providers for full benefits. The choice between the two depends on individual preferences and healthcare needs.
Types of Medicare Advantage plans
Medicare Advantage plans, also known as Medicare Part C, offer a comprehensive alternative to receive your Original Medicare benefits, providing coverage beyond what traditional Medicare offers. These plans come in several types, each designed to meet different healthcare needs and preferences. From Health Maintenance Organization (HMO) plans offering cost-effective care within a network of providers to Preferred Provider Organization (PPO) plans providing flexibility to see out-of-network providers for a higher cost, there’s a variety of options available. Additionally, Special Needs Plans (SNPs) cater specifically to individuals with certain chronic conditions or disabilities, or who also have Medicaid ensuring tailored care. Understanding these types of Medicare Advantage plans empowers individuals to choose the option that best fits their healthcare needs and budget.
| Medicare Advantage Plan | Plan Details |
| Health Maintenance Organization (HMO) | An HMO plan requires you to use doctors, hospitals, and other healthcare providers within its network. Generally, you need a referral from your primary care physician to see a specialist. These plans focus on integrated care and preventive health services. |
| Preferred Provider Organization (PPO) | A PPO plan allows more flexibility in choosing healthcare providers. You don’t need referrals for specialists and can use services outside the network, though at a higher cost. It offers a balance between organized care and freedom to choose providers. |
| Private Fee-For-Service (PFFS) | PFFS plans are unique because they allow you to see any healthcare provider who accepts the plan’s payment terms. The plan determines how much it will pay providers and how much you must pay when you receive care. It offers flexibility in choosing providers without the need for a network. You can see any of the network providers who have agreed to always treat plan members. |
| Special Needs Plan (SNP) | SNPs cater to specific groups of people, including those with certain chronic conditions, those eligible for both Medicare and Medicaid, or those living in certain institutions. These plans tailor their benefits, provider choices, and prescription drug formularies to meet the specific needs of the groups they serve. |
| Medical Savings Account (MSA) | MSA plans combine a high-deductible insurance plan with a medical savings account. Medicare allocates a yearly sum to your plan for covering your healthcare expenses, which can be utilized to pay for your healthcare services. Once the deductible is met, the plan covers your healthcare costs. It’s suitable for those who prefer a high-deductible plan paired with savings for healthcare expenses. |
| HMO Point-of-Service (HMO-POS) | This plan is a variation of the standard HMO. It allows you to receive some services outside of the plan’s network for a higher copayment or coinsurance. It offers a mix of the strict network restrictions of an HMO with the flexibility to go out-of-network like in a PPO plan. |
Comparing Medicare Advantage plans may involve weighing the balance between network restrictions, provider flexibility, and financial considerations unique to each plan type. Health Maintenance Organization (HMO) plans are known for their coordinated care within a tight-knit provider network, whereas Preferred Provider Organization (PPO) plans offer more freedom to see in-network and out-of-network providers without referrals, at a higher cost. Private Fee-For-Service (PFFS) plans provide the utmost flexibility by allowing visits to any provider that accepts the plan’s payment terms. Special Needs Plans (SNP) are tailored for individuals with specific health conditions, offering targeted benefits and networks. Medical Savings Account (MSA) plans encourage proactive financial management of healthcare expenses through a high-deductible plan coupled with a savings account. Choosing the right plan hinges on individual healthcare needs, desired flexibility in choosing providers, and how one prefers to manage healthcare costs.
What do Medicare Advantage plans cost?
The cost of a Medicare Advantage plan can vary depending on several factors, including the specific plan you choose, and your location. In general, Medicare Advantage plans typically have their own monthly plan premiums, which are in addition to the standard Medicare Part B premium. Some Medicare Advantage plans may offer a plan premium as low as $0 , while others may have monthly plan premiums that can range from a few dollars to over a hundred dollars.
In addition to the monthly plan premiums, Medicare Advantage Plans (Medicare Part C)may also have other costs, such as deductibles, copayments, and coinsurance. Medicare Advantage plans costs can vary between plans and may depend on the type of services you receive. Some Medicare Advantage plans have lower out-of-pocket costs for certain services, while others may have higher costs but provide additional coverage, such as dental, vision, or hearing coverage.
It’s important to carefully review the costs and coverage of different Medicare Advantage Plans to determine which one best fits your needs and budget. Additionally, you may be eligible for financial assistance, such as Extra Help, which can help reduce your out-of-pocket costs for a Medicare Advantage Plan (Medicare Part C).
Enrolling in a Medicare Advantage plan
Enrolling in a Medicare Advantage plan requires meeting specific eligibility criteria. Primarily, individuals must be enrolled in both Medicare Part A and Part B, which typically means they are 65 years of age or older, though some younger individuals with disabilities or certain conditions like End-Stage Renal Disease (ESRD) or ALS (also called Lou Gehrig’s disease) may also qualify. It’s also necessary to reside in the service area of the Medicare Advantage plan you wish to join. Unlike Original Medicare, Medicare Advantage plans are offered by private insurance companies approved by Medicare and can vary in availability and options based on geographic location. Understanding these eligibility requirements helps move you towards understanding and potentially selecting a Medicare Advantage plan that aligns with your healthcare needs and preferences.
Medicare Advantage enrollment eligibility
To qualify for a Medicare Advantage plan, you must meet the following criteria:
- Enrolled in Medicare Part A and Medicare Part B: You must be enrolled in both Medicare Part A, which covers hospital services, and Medicare Part B, which covers medical services, before you can enroll in a Medicare Advantage plan.
- Reside in the plan’s service area: Medicare Advantage plans are offered by private insurance companies and have specific service areas. To be eligible, you must reside in the service area of the Medicare Advantage plan you wish to enroll in.
Be a U.S. citizen or lawfully present in the U.S.
It’s important to note that while most people are eligible for Medicare Part C, the availability of specific Medicare Advantage plans may vary depending on your location. It’s recommended to review the plans available in your area and compare their benefits, costs, and network of providers to choose the one that best meets your healthcare needs.
How to enroll in a Medicare Advantage plan
Enrolling in Medicare Advantage is a straightforward process during the Medicare Open Enrollment period. To enroll, you need to meet the eligibility requirements and follow the enrollment guidelines. Medicare Open Enrollment typically occurs from October 15th to December 7th each year.
To enroll in a Medicare Advantage plan, follow these steps:
- Determine your eligibility: Before enrolling in Medicare Advantage plan make sure you meet the eligibility requirements listed above.
- Research and compare Medicare Advantage plans: There are various Medicare Advantage plans available, offered by different insurance companies. Research and compare the plans available in your area to find the one that best suits your healthcare needs. Consider factors such as premiums, deductibles, copayments, network of providers, and additional benefits.
- Enroll during the appropriate enrollment period: There are specific enrollment periods during which you can sign up for Medicare Advantage plan.
- The initial enrollment period (IEP) occurs when you first become eligible for Medicare, typically around your 65th birthday.
- There’s also a Medicare annual enrollment period (AEP) from October 15 to December 7, during which you can switch or enroll in a Medicare Advantage plan.
- Additionally, there may be other enrollment periods, such as special enrollment periods (SEPs), for individuals who experience qualifying life events.
- Enroll directly with the plan or through Medicare: Once you’ve chosen a Medicare Advantage plan, you can enroll directly with the insurance company offering the plan or through the official Medicare website (Medicare.gov) or by calling 1-800-MEDICARE. Follow the instructions provided by the chosen method to complete your enrollment.
Remember to carefully review the terms and conditions of the Medicare Advantage plan you’re considering, as well as its coverage and costs, to ensure it aligns with your healthcare needs and budget.
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MMR 1758-2024