Medicare Advantage Plans (Part C)
If you qualify for or already have Original Medicare, you can instead, choose to enroll in a Medicare Advantage Plan from a qualified private health insurance company.
Medicare Advantage Plan options must be approved by Medicare and offered by private companies. These plans are part of Medicare and are technically Medicare Part C. These companies must follow rules set by Medicare. These plans will provide your Medicare health coverage and in some instances, your Medicare drug coverage as well.
Medicare Advantage plans are not considered the same as a Medicare Supplement (Medigap) policy.
Medicare Advantage Plans will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. This means that they must cover at least all of the services that Original Medicare covers. Each Medicare Advantage Plan can charge monthly premiums and also have different copayments and maximum out of pocket amounts and may offer for an extra coverage special extras such as vision, hearing, dental, and/or health and wellness programs. Medicare Advantage Plans must be resubmitted and approved by Medicare on an annual basis. Insurance companies that administer Medicare Advantage plans have the option, and generally do, change the plans benefits from year to year.
All Medicare Part C coverage includes emergency and urgent care. Medicare Part C coverage does not include hospice care but that benefit remains with Original Medicare even if you have a Medicare Advantage Plan.
Types of Medicare Advantage (Part C) Plans
It’s important to review the differences between the types of plans to see which works best for you. There are several different types of Medicare Advantage Plans:
HMO (Health Maintenance Organization Plan) – allows you to see doctors and other health professionals that participate in its network. If your doctor is already in that network, it could be a good option because you tend to pay less out of your own pocket with network doctors.
PPO (Preferred Provider Organization Plan) – gives you the freedom to choose any doctor, which can work for you if you prefer that kind of flexibility.
PFFS (Private Fee-for-Service Plan) – pays a specific amount for health care services and the treating doctor has to accept that amount – even if it is less than his or her usual charge. If the doctor does not agree to those terms, then Medicare will not cover services through that doctor.
SNP (Special Needs Plans) – is especially for people who have – as its name implies – special needs. That includes (but is not limited to) those living in a nursing home, Medicaid-eligible individuals, and people with chronic diseases or disabling conditions, like diabetes, ESRD or HIV/AIDS. This type of plan always includes prescription drug coverage while other types of plans may or may not.
Eligibility for Medicare Part C
Medicare Part C eligibility is based on your eligibility for Medicare Parts A and B (except if you have End Stage Renal Disease (ESRD)). Generally, if you have Medicare Parts A and B, you are eligible for Medicare Part C. However, you must live in the service area for the Medicare Advantage Plan that you’re considering. The service areas may be more limited than Original Medicare.
If you have other health insurance coverage, for example through your employer or union, you must find out their rules before you enroll in a Medicare Advantage Plan. You may lose your other coverage if you enroll in the Medicare Advantage Plan. But that’s not a hard and fast rule. It’s best to talk it over with the other plan’s benefits administrator. If you drop the other plan, you might not be able to get it back if you change your mind later.
Enrollment in Medicare Part C
The enrollment process for Medicare Advantage plans will differ depending on which private insurer you chose. But the enrollment periods are the same everywhere. You can enroll in a Medicare Advantage Plan (Part C) when you first become eligible for Medicare. It is a seven-month period that starts three months before your 65th birthday through four months after your birthday. If you are under age 65 and you receive Social Security disability, you qualify in the 25th month after you begin receiving your Social Security benefits.
If you are already enrolled in Original Medicare, then you must wait until the next enrollment period to sign up for Medicare Advantage. The annual enrollment period is October 15 through December 7 Coverage begins on January 1 of the new year.
If, after enrolling in a Medicare Advantage Plan, you change your mind, you can switch back to Original Medicare from January 1 through February 14 each year. If you disenroll from a Medicare Advantage Plan that included prescription drug coverage, you would need to sign up for a Medicare Part D plan during this same time frame.
Generally, once you enroll, you stay enrolled until the next annual election period becomes available. However, there are some situations that might qualify you to make a change during the rest of the year. An example of these situations include (this is not an all-inclusive list):
- You move outside your Medicare Advantage Plan’s service area
- You qualify for Extra Help (a program to help you afford prescription drugs)
- If you move into an institution (such as a nursing home)