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Medicare Part C (Medicare Advantage)

Medicare Part C

Medicare Part C, also called Medicare Advantage, allows you to get customized Medicare insurance. It is offered by private insurance companies. Every plan is different. However, they are all required by law to provide you with at least the same coverage you would have with Medicare Part A and Medicare Part B (original Medicare).

Medicare Advantage provides you with all of the coverage you have with Medicare Part A (in-patient care and services) and Medicare Part B (outpatient care and services) including:

  • Services you receive from an inpatient or outpatient stay in a hospital
  • Diagnostic procedures like laboratory test and X-rays
  • Operating room services
  • Emergency room services
  • Rehabilitation services
  • Ambulatory surgery center and outpatient medical services
  • Doctor office visits
  • Diagnostic procedures like laboratory test and X-rays
  • Durable medical equipment for use at home

All of the covered services must be medically necessary, short-term services designed to help you regain your health and mobility.

Medicare Advantage doesn’t cover the entire cost of these services. You must contribute to the payment of your own medical bills. Most services will require a co-payment or co-insurance.

Beyond Original Medicare

You may choose a Medicare Advantage plan that provides you with services that are not part of original Medicare such as:

  • Prescription drug coverage
  • Dental care
  • Vision care
  • Hearing care
  • Medicare treatment you receive outside of the United States

See your plan details to find out what additional services you may have. Contact your Medicare Advantage insurance provider if you have additional questions.

Medicare Part C & Doctors

With Medicare Part C, the medical professionals you use depends on your plan.

  • Some Medicare Advantage plans require you to use a primary care physician who coordinates your care with medical specialists and facilities. You must use medical professionals who are part of the plan network and your plan may require you to get referrals before you can see a specialist.
  • Other Medicare Advantage plans allow you to see any Medicare-eligible provider. You will probably pay more from doctors or facilities that are out of the contracted network.

All Medicare Advantage plans are required to cover you at the in-network cost if you require urgent or emergency care anywhere in the United States.

Medicare Part C Eligibility

Everyone enrolled in Medicare Part A and Part B (original Medicare) can enroll in Medicare Advantage with a few limitations.

  • You must live in the service area.
  • You cannot have End Stage Renal Disease (ESRD). There are exceptions to this rule.
  • Some Special Needs Plans (SNP’s) have additional eligibility requirements.

You can’t be refused for Medicare Part C insurance because of your medical history or a pre-existing condition other than ESRD.

Medicare Part C Costs

Your costs for Medicare Part C include:

  • Premium. Everyone enrolled in Medicare Advantage must continue to pay their premium for Medicare Part B (and Part A if you don’t qualify for premium free Part A. Your Medicare Advantage plan may also have a monthly premium. The company that provides your Medicare Advantage plan sets the premium.
  • Deductible. Some Medicare Part C plans charge a deductible while others do not. A deductible is the amount of your medical expenses you must pay out of pocket before your Medicare insurance starts covering your bills. Check your Medicare Advantage plan “Evidence of Coverage” (EOC) for details.
  • Copay or coinsurance. Medicare Advantage plans charge a copay or coinsurance for each service they provide. A copay is a fixed amount that you must pay each time you use a service. Coinsurance is typically a percentage of the Medicare allowable fee or contracted rate. Those costs are spelled out in the Evidence of Coverage.

With Medicare Advantage, there is a maximum out-of-pocket expense you are responsible for each calendar year. Once your expenses reach that set amount, you no longer pay anything for Medicare Covered services. You are still required to pay the premium if your plan has one. There is no maximum out of pocket expense with original Medicare.

When you enroll in a Medicare Advantage plan, you cannot get a Medicare supplement (Medigap) insurance policy. Medigap policies only pay after original Medicare and since your private plan is now responsible for your costs, a Medigap policy cannot pay. With most Medicare Part C plans, you also cannot purchase a standalone prescription drug plan (Medicare Part D) because prescription drug coverage is included in your plan. In fact, enrolling into a Stand-Alone drug plan will disenroll you from your Medicare Advantage plan.

Now, let’s talk about the types of Medicare Advantage plans.