Medicare Part C


Medicare Parts A and B by design do not cover all of your hospital and physician costs and must be supplemented through private insurance carriers in order for you to have comprehensive and unlimited benefits.

Medicare Part C plans fall into two broad categories: Medicare Supplements (sometimes called Medigap plans) and
Part C/Medicare Advantage plans. You must be enrolled in both Medicare Part A and Part B to qualify for any type of Medicare Supplement or Advantage plan.

This chart shows your potential out-of-pocket costs for treatment received under Parts A and B.




MEDICARE ADVANTAGE PLANS (MA and MA-PD)

Health treatment under most Part C/Medicare Advantage MA-PD/MA plans is administered through networks of participating providers: HMOs (health maintenance organizations), POS (point of service) and PPO options.

An HMO requires its members to see only providers that are in that Company's network and, except under unusual circumstances, will not pay for treatment by non-network providers. You must select a Primary Care Provider (PCP) and referrals are usually necessary to see a specialist.

A POS is an HMO but, unlike a basic HMO, it will also pay if an insured is treated by a non-network provider. Note that it will pay the non-participating provider the same amount that it would a network provider and, consequently, you may be liable for substantial balance billing from that non-participating provider.

A PPO also has a network but, unlike an HMO, it does not require you to select a PCP or to obtain a referral when seeing a specialist. It will also permit you to see a provider that is not in the network but, as with a POS, you may be liable for significant balance billing if you do. Note that all network and non-network providers under the POS and PPO options must be licensed with and accept Medicare.

Most - but not all - Medicare Advantage plans include prescription drugs as part of their coverage. If you select an Advantage MA plan that does not include prescription coverage, you will NOT be allowed to enroll in a stand-alone drug card to go with it and you will not have drug coverage as long as you are on that specific Advantage plan. If you do enroll in a Part D plan while you are also on an MA or MA-PD plan, Medicare will disenroll you from the MA or MA-PD plan and you will have to return to Original Medicare.

A Medicare Advantage plan that you purchase as an individual replaces Medicare and will be your primary health insurance, even though you must maintain your enrollment in both Medicare Part A and Part B. Do not use your Medicare card to obtain medical treatment when you have an Advantage plan. Use only the card the insurance company sends you.

Medicare Advantage plans resemble non-Medicare health insurance coverage in the way they function. Your medical treatment will often require you to make co-pays to your providers and hospitals, and sometimes deductibles and co-insurances for certain treatments. In addition, many insurance carriers attach benefits to their plans that vary from company to company - gym reimbursements, dental, hearing aid, and vision discounts, for example. Such benefits are not part of Original Medicare and can make such plans very attractive to the consumer.

How Can I Change My Plan?

The Annual Enrollment Period (AEP) begins on October 15 and ends on December 7 each year. You can make changes freely to your current Part C and Part D coverages throughout this period and any changes will take effect on January 1st of the next year.

You may need to make changes to your coverage during the year outside the AEP in what are known as Special Election Periods (SEP), which are for certain types of qualifying events:

  • You lose coverage under your employer's plan
  • You move from the county in which you live
  • Your plan changes its contract with Medicare
  • You can obtain other coverage through an employer, union, or other government plan
  • Certain other unusual situations

As a rule, your SEP for Medicare Parts C and D will begin the first of the month following the month that the qualifying event takes place and ends two months later. Your SEP for Medicare Parts A and B will end at the end of the 8th month that your SEP began. If you do not apply for Part B or Part D by the end of your SEP you will be subject to late-enrollment penalties.

MEDICARE SUPPLEMENT PLANS

Medicare Supplement plans have a number of different plan options (see chart). These options are identical from one insurance company to another. A Plan F offered by a Blue Cross, for example, is identical to a Plan F offered by Mutual of Omaha or CIGNA. The only differences among different companies for a given plan are the price and any add-on benefits that a given company may offer in addition to the core plan benefits e. g. gym reimbursements, vision and glasses, and so forth.

Medicare Supplements have no provider networks. A Medicare Beneficiary with a Supplement can go to any medical provider in the United States that accepts payment from Medicare, and no referrals are required to see a specialist.

Medicare Supplements are medically underwritten except under certain defined circumstances. You may enroll in any insurance company's Medicare Supplement plans without having to prove insurability during the three months before and three months following the month in which you qualify for Medicare. If you lose health insurance through your or your wife's employer through no fault of your own, or you move from the county in which you enrolled in your Medicare Advantage plan or that plan stops being offered in that county by the insurance company, you may enroll in a Medicare Supplement through an insurance company of your choice as guaranteed issue.

Medicare Supplement plans are true supplements in that they "fill in" the gaps that were designed into original Medicare and they are secondary to Medicare itself. You will need to carry your Medicare card with you as well as your Medicare Supplement card.

Original Medicare A and B and Medicare Supplements do not offer out-patient prescription coverage and if you need your prescriptions to be covered you must enroll in a so-called "Part D" plan for this part of your insurance.

MEDICAL SAVINGS ACCOUNTS

Medical Savings Accounts (MSA) are a type of Medicare Advantage plan that are increasingly popular in the areas in which they are offered. They combine a high deductible - $3,000, for example - with a tax-qualified savings account into which Medicare deposits a sum of money equal to a predefined portion of that deductible. MSA plans have no premium; you do not need to pay anything to the insurance company. As with any Advantage plan you must be enrolled in Part A and Part B of Medicare to enroll. MSAs do not include prescription medication coverage and you will need to choose a Part D card for your medications.

There are no provider/hospital networks with an MSA plan; you can go to any doctor or hospital that accepts Medicare. You do not need a referral to see any doctor with this type of coverage.

Medicare sets up an MSA bank account for you and deposits a sum of money into the account when it is initially created, and on the first of each succeeding year, equal to a specified percentage of your deductible. For example, if your MSA plan has a deductible of $3,000 and Medicare deposits 50% of that deductible for that year, you would have $1,500 in your MSA account. You use the money that Medicare deposits into your MSA bank account to pay for any medical treatment you may need. If your medical treatments exceeds the balance in the MSA account you would need to pay the remainder of the deductible out of your own pocket. Once the deductible has been reached the insurance company pays 100% of your medical bills thereafter.

If your medical expenses do not exceed the balance in your MSA bank account at the end of the year, the money that remains in the account rolls over and Medicare will add another deposit to the account on the first of the next year. The MSA monies accumulate in your bank account if you do not use them.

MSAs are frequently attractive to the consumer because, even though they carry a higher deductible, the fact that they are free to the consumer and that Medicare pays a part of that deductible can make them, on balance, the least expensive and most flexible solution for your Medicare needs.

Introduction To Medicare

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Medicare Part A & B

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Medicare Part C

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Medicare Part D

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What Do They Cost?

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Compare Plans

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