What Does Medicare Part C Cover? Today is the second part of a series on Medicare and what coverage is provided by Medicare Advantage.
Medicare Part C is the official term for what people usually call Medicare Advantage. Instead of using Medicare Parts A and B, also called “original Medicare,” you have the option to purchase a private health insurance plan. Medicare Advantage usually provides benefits that are similar to Parts A, B, and D (drug coverage). You will typically have an HMO or PPO, with an approved network of doctors, if you select a Medicare Advantage plan.
Health maintenance organizations (HMOs) provide health insurance coverage for a monthly premium. An HMO limits member coverage to medical care provided through a network of doctors and other healthcare providers who are under contract to the HMO. These contracts both allow for premiums to be lower than for traditional health insurance because the health providers have the advantage of having patients directed to them but they also add additional restrictions to the HMO’s members.
A preferred provider organization (PPO) is a medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates. PPO medical and healthcare providers are called preferred providers. PPO plans tend to charge higher premiums because they are costlier to administer and manage. However, they offer more flexibility compared to alternative plans.
What Does Medicare Part C Cover? What Medicare Advantage Plans Cover
Medicare Advantage (MA) plans provide the same services as original Medicare (Parts A and B). Most MA plans include coverage for prescription drugs, similar to Medicare Part D.
There are many different Medicare Advantage plans. Private health insurance companies offer MA plans. You do not buy MA from the government.
The terms of the coverage will depend on the individual MA plan. For example, some Medicare Advantage plans have a higher annual deductible than original Medicare.
Terms of Medicare Advantage Plans
Original Medicare has a 20 percent copay, after you satisfy the annual deductible. Some MA plans charge a different amount of copay. Your copay might depend on the type of service you receive, like a primary care physician or a specialist. With some MA plans, you have to pay a set amount for each day you are an inpatient in the hospital. With other MA plans, you might have to pay a traditional copay, which is a portion of the total hospital bill.
Your MA HMO or PPO will have a list of approved service providers (doctors and hospitals). If you go to a doctor or hospital that is not in your plan’s network, you might have to pay a much higher portion of the bill. In some situations, the MA plan might not cover the expense at all.
What to Do When Your MA Plan Changes
Your Medicare Advantage plan can change every year, effective on January 1. Annually there is an open enrollment period. You will get information about upcoming changes every September. Be sure to read the terms of your coverage every year during the open enrollment period to make sure you still have the coverage you want. You can switch your coverage during open enrollment for a plan that meets your budget and other needs.
Most people find that Medicare Advantage plans are closer to the group health insurance coverage they had through their employer. You will select a primary care physician in your area. Depending on your plan, you might need a referral from your primary care doctor before you go to a specialist.
How to Enroll in a Medicare Advantage Plan
Here are the steps for getting coverage through Medicare Advantage:
- You enroll in Medicare Parts A and B in your service area.
- You pay your Medicare Part B premium while in a Medicare Advantage plan. (Most people do not have a Part A premium. Some MA plans have a $0 monthly premium.)
- Medicare pays a flat amount to your Medicare Advantage plan to provide your medical care. You receive all of your Part A and B healthcare through your Medicare Advantage plan.
All Medicare Advantage plans protect you with an out-of-pocket maximum. The maximum applies to Part A and Part B services. The carriers calculate Part D (drugs) out-of-pocket costs separate from the annual maximum.
Every state has different regulations. You might want to talk with an elder law attorney near you to find out how your state might vary from the information in this article.
Boomer Benefits. “What is Medicare Advantage?” (accessed October 24, 2019) https://boomerbenefits.com/medicare-advantage/what-is-medicare-advantage/