Medicare Part C is available through Medicare Advantage plans, and is an alternative to Original Medicare (Parts A and Part B). Medicare Advantage plans are health insurance plans offered by private health insurance companies approved by Medicare. Medicare Advantage health plans (such as HMO, PPO or PFFS plans) are legally required to offer at least the same benefits as Original Medicare, but can include additional coverage as well, such as routine vision or dental benefits, health wellness programs, or prescription drugs.
One benefit of Medicare Advantage plans is that you can get your prescription drug benefits (Medicare Part D) included under the same plan, instead of having to enroll in a separate stand-alone Medicare Prescription Drug Plan. These plans give you the convenience of having your Medicare Part A, Part B, and Part D coverage through a single plan.
What are the different types of Medicare Advantage plans?
As mentioned, Medicare Part C coverage details can vary depending on the insurance company, so it’s always a good idea to compare the Medicare Advantage plan options in your specific location. The following are types of Medicare Advantage plans that may be available in your location:
Health Maintenance Organization (HMO) plans: These plans offer a network of doctors and hospitals that members are generally required to use to be covered. Because of this, HMOs tend to have strict guidelines, meaning that any visits and prescriptions are subject to the plan approval. If you use providers outside of the plan network, you may need to pay the full cost out of pocket (with the exception of emergency or urgent care). You generally need to get a referral from your primary care doctor to see a specialist.
Preferred Provider Organization (PPO) plans: Medicare Advantage PPO plans offer a network of doctors and hospitals for beneficiaries to choose from. Unlike an HMO, you have the option to receive care from health-care providers outside of the plan’s network, but you’ll pay higher out-of-pocket costs. Medicare Advantage PPOs don’t require you to have a primary care doctor, and you don’t need referrals for specialist care.
Private Fee-for-Service (PFFS) plans: This type of plan allows visits to any Medicare-approved doctor or hospital, as long as the plan’s terms and conditions of payment are accepted by the provider. Keep in mind that you’ll need to find providers that contract with the plan each time you are receiving treatment.
Special Needs Plans (SNPs): These plans limit enrollment to beneficiaries who have certain chronic conditions, are institutionalized, or qualify for both Medicare and state Medicaid (also known as dual eligibles). Benefits, provider options, and prescription drugs are tailored to meet the needs of the plan’s enrollees.
How do I know if I am eligible for a Medicare Advantage plan?
In order to be eligible for Medicare Part C, you must be enrolled in both parts of Original Medicare (Part A and Part B). Once you have Medicare Part A and Part B, you are generally able to enroll in a Medicare Advantage plan, provided you live in the plan’s service area and do not have end-stage renal disease (ESRD).
There are some exceptions where you may be able to enroll in a Medicare Advantage plan even if you have end-stage renal disease. For example, if you’re enrolling in a Special Needs Plan that targets beneficiaries with end-stage renal disease, you may be eligible to enroll in this type of Medicare Advantage plan.
To learn more about other situations where you may be eligible for Medicare Part C if you have end-stage renal disease, you can contact us using the contact page on this site. You can also contact Medicare at 1-800-MEDICARE (633-4227); 24 hours a day, seven days a week.
Those with other health insurance coverage (a union or employer-sponsored health plan, for example) should get more information about their existing coverage before enrolling in a Medicare Advantage plan. It is possible you could lose your existing coverage once you enroll in a Medicare Advantage plan. Furthermore, if you discontinue the other plan for Medicare Part C coverage, you may not be able to reinstate your original coverage if you change your mind. It is generally a good idea to check with your current benefits administrator before you enroll in another health-care plan.
If you’d like to learn more about Medicare Advantage plan options or if you’d like help finding coverage that may fit your needs, you can call me directly at 207-370-0143 or use my simple form on the CONTACT page of this site to send an email message.
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