Medicare Part C

Private Insurance Plans “Medicare Advantage”

Coverage

Medicare Part C is best known as “Medicare Advantage,” an optional program providing a variety of private insurance options that combine the benefits included in Medicare Part A (inpatient hospitalization services), Part B (outpatient, medically necessary services), and Part D (prescription drugs) into one plan. They will also cover most dental, vision, and hearing exams and a portion of costs associated with fillings and crowns, eyeglasses, and hearing aids.

 

Medicare Advantage Plans are intended to help offset costs for the insured by offering a variety of coverage and payment options. They require you to be enrolled in both Medicare Part A and Part B. The Medicare Advantage Plan you select must also operate its service area within the same county as the address you reside (location on file with Social Security).

 

Medicare Advantage Plans are comparable to the insurance model you received during employment. In addition to having in-network providers, you will also be responsible for co-pays at the time most services are received (both inpatient and outpatient).

 

There are many different variations of Medicare Advantage plans available. The HMO model of care will generally have the lowest co-pays and annual out-of-pocket maximum. In exchange for these benefits, you will be required to use network providers only. The PPO model of care typically has higher co-pays and annual out-of-pocket maximums than the HMO model, but you will be able to utilize both in- and out-of-network providers (you will pay more to see an out-of-network provider).

 

Costs

Premiums

Premiums for Medicare Advantage plans are handled a bit differently. Medicare actually pays a fixed monthly sum to the insurance carrier to cover costs associated with your medical care, which helps offset the cost you would have otherwise incurred. Based on the amount still owed, the Medicare Advantage Plan’s insurance carrier will determine your monthly premium, which is often made as low as possible — many are $0 premium and now we are beginning to see more and more “giveback” plans which will return a portion of your Medicare part B premium to you.

 

Unlike Part A and Part B, Medicare Advantage plans are dependent on the Medicare contract that supplements the overall rate. Because this contract is negotiated each year, this can cause fluctuations in costs related to premiums, co-pays, and prescriptions.

 

Out-of-Pocket Costs

Each year, Medicare sets the annual out-of-pocket maximum amount you’ll pay under a Medicare Advantage Plan. It’s important to note this only covers costs for medical services included in Medicare Part A and Part B. For 2021, the out-of-pocket maximum is $7,550.

 

Look closely at the Medicare Advantage Plans; many insurance companies offer lower out-of-pocket maximums than Medicare’s maximum amount of $7,550. This is an important consideration for both financial planning and determining what amount is most reasonable for you to pay given your health needs.

 

If you’re having difficulty finding a Medicare Advantage Plan under Part C that aligns with your current situation, you may want to explore Medigap coverage, which reduces the amount you are required to pay following delivery of medical services.

Considerations

  • Medicare Advantage Plans will vary, so review the benefits and medical service coverages closely. This will allow you to compare co-pay and co-insurance costs for services, prescription drug formulas, as well as the maximum out-of-pocket rates, as you determine the plan that is best for you.
  • Every payment you make for a service covered under Part A and Part B goes toward your out-of-pocket maximum. When you reach your annual limit, your Medicare Advantage Plan will cover all costs for the remainder of the year.
  • Be familiar with the election period for your Medicare Advantage Plan, which will offer guidance on enrollment periods and enrollment-related to special circumstances.
  • Consult with our licensed Medicare experts who can assist with navigating the unique requirements of Medicare Advantage Plans, as well as keep you informed of the time-restricted enrollment periods.

Enrollment

Enrollment into Part C Medicare plans can only take place during specific timeframes. The easiest option is to enroll at the same time you sign up for Part B — during your Initial Enrollment Period.

 

Part C Medicare Plans also have Election Periods, to afford you the opportunity to change your plan if you don’t like the benefit rates or changes being made for the coming year. Remember, Medicare Advantage Plans are subject to change each year depending on the Medicare contract negotiated.

 

  • The annual Election Period is October 15 – December 7 (benefits begin January 1).
  • Medicare Advantage Open Enrollment Period is January 1 – March 31.
  • Special Election Periods are also available to accommodate life events, such as moving out of your plan’s service area or no longer receiving employer group insurance coverage.