Understanding Medicare Part C and What it Covers

Understanding Medicare Part C and What it Covers

What Is Medicare Part C?

To understand Medicare Part C, commonly referred to as Medicare Advantage, it is important to know that it is an alternative to Original Medicare and is run by private insurance companies. Medicare Part C provides everything Medicare Part A (hospital insurance) and  Part B (medical insurance) do, in addition to offering coverage for things like vision, dental, hearing, and prescription drugs. Medicare Part C is optional and there is no penalty for not signing up.

As long as you are enrolled in Medicare Part A and B, you can enroll in Medicare Part C. Just like enrolling in Parts A and B, signing up for a Medicare Advantage plan and/or a Medicare prescription drug plan can occur during a seven-month period that:

  • Starts three months before the month you turn 65
  • Includes the month you turn 65
  • Ends three months after the month you turn 65 
If you join Your coverage begins
During one of the 3 months before you turn 65 The first day of the month you turn 65
During the month you turn 65 The first day of the month after you ask to join the plan
During one of the 3 months after you turn 65 The first day of the month after you ask to join the plan

Each year, you can make changes to your Medicare Advantage or Medicare prescription drug coverage for the following year. There’s a fall Open Enrollment Period (OEP) when you can sign up for a Medicare Advantage plan, switch from one Medicare Advantage plan to another, or drop your plan and return to Medicare Part A and Part B. This period is called the Annual Election Period (AEP), and it runs from October 15 to December 7.

On the other hand, you may have waited to sign up for Medicare Part C if you were working for an employer when you turned 65 and had healthcare coverage through your job or union, or through your spouse’s job. This would allow you to enroll in a Part C Medicare Advantage plan during the Special Enrollment Period (SEP) which is 63 days after the loss of employer healthcare coverage.


Who Is Eligible for Medicare Part C?

Any Medicare beneficiary, regardless of age, can purchase Medicare Part C. However, you must be already enrolled in Medicare Part A and Part B in order to be eligible for Medicare Part C. Additionally, you must reside within the service area of the Medicare Advantage plan you want.

Here’s what you need to know about Medicare Part C eligibility:

  • You must be enrolled in both Medicare Part A and B. Many people think they can drop Part B if they enroll in a Medicare Part C plan; however, this is wrong. If you drop Part B, you will immediately be kicked out of your Part C plan.
  • You need to live in the plan’s service area. This Medicare Part C eligibility will be based on the address that you have on file with Social Security. You must choose a plan that operates in that same county. Some plans will be specific to only one or two counties, while others might span the whole state.
  • You must not have End stage renal disease. This is the only medical question on the Part C application.

Note that Medicare Advantage plans have election periods. This means that you can enroll in the plan during your Initial Enrollment Period or during the Annual Election Period in the fall. There are also certain Special Election Periods  for certain circumstances like moving out of state and losing your plan. In this scenario, you would be granted a SEP to enroll in a plan mid-year in your new state.

Types of Medicare Part C Plans

There are three plans associated with Medicare Advantage. They are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-For-Service (PFFS) plans.

With HMOs, a primary care doctor in a network is chosen by you. That doctor will be responsible for your care and give you referrals to see a specialist.

PPOs have network and out-of-network doctors that you can see and facilities you can use, often without a referral.

A PFFS plan determines whether it will accept Medicare insurance, how much it will pay doctors, other health care providers and hospitals, as well as how much you must pay when you get care. This plan does not require you to choose a primary care physician and you do not need a referral from a primary care physician to see a specialist.

Primary doctor All of the doctors are in a network and your primary doctor is chosen by you. Doctor referral to a specialist is required. Network and out-of-network doctors you can use without a referral No requirement to choose a primary doctor. No referral needed to see a specialist.
Out-of-pocket costs Minimal as you are using doctors in a specific network. Higher as you have more choices of providers. You can see a doctor inside or outside your network, but if you stay inside your network, you will pay less. Depends on whether the provider accepts your insurance. As a result, you will need to get written acceptance before each service or risk paying the bill in full.
Emergency coverage outside the U.S. Yes, limited coverage Yes, limited coverage Yes, limited coverage


What Are the Costs Associated with Medicare Part C?

The extra coverage provided by Medicare Part C is good, but it does come with extra costs. You can’t opt out of Medicare Part A and Part B, so keep in mind that if you decide to enroll in Medicare Part C, you must pay for it and continue paying the Part B premium.

Medicare Part C premiums vary depending on the type of plan and the state you live in. The average monthly premiums are usually lower than what you would pay for Medicare Part B. However, you still have to pay your annual deductible, copayments, and coinsurance for your Part C plan.

Each year, plans establish the amounts they charge for premiums, deductibles, and services. Only some Medicare Advantage plans have an annual deductible, in addition to the standard Part B deductible. Plans that include prescription drug coverage may charge another deductible for drug coverage.

Copayments are for specific services such as doctor visits. Usually copays are a flat dollar fee. Some types of plans charge higher copays to see providers out of your network.

Each Part C plan can charge different out-of-pocket costs and have different rules for how you get services including whether you need a referral to see a specialist or have to go to only doctors that belong to the plan for non-emergency or non-urgent care.

Keep in mind that these rules can change each year. However, what you pay may change only once a year, on January 1. To learn about Medicare Advantage, Supplement and prescription drug plans, request a free quote.