MEDICARE PART C
Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Managed Care Plan, and formerly known as Medicare+Choice, is the part of Medicare concerning private health plans. It lets you get your Medicare benefits from a private health plan contracted by the government to provide this coverage. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs and coverage restrictions. Some plans (MAPDs—Medicare Advantage Prescription Drug Plans) offer Part D drug coverage as part of their benefits packages. You must have Medicare Part A and Part B to join a Medicare Advantage Plan. Medicare Advantage Plans include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), PFFS (Private Fee-for-Service) plans, SNPs (Special Needs Plans) and MSAs (Medical Savings Accounts), and may have a POS (Point-of-Service) option.
What Are Medicare Part C Costs?
Before you choose to enroll in a Part C (private Medicare Advantage or MA) health plan, you should check to see what costs you may have. These costs may include:
Part C Medicare Premiums
In 2022, the average monthly MA plan premium is $19 per month according to the Center for Medicare and Medicaid (CMS), but this premium may vary significantly between plans, anywhere from $0 to over $100. Remember that you must have Medicare Parts A & B to join a Medicare Advantage plan.
You pay your usual Part B premium plus any additional premium that the plan may charge. Some MA plans may pay a portion of your Part B premium; check with the plan to see if this is the case.
Part C Medicare Deductibles
Only some Medicare Advantage Plans have an annual deductible, in addition to the standard Part B deductible. Plans that include prescription drug coverage may charge another deductible for drug coverage.
Copayments are for specific services, such as doctors’ visits. Usually copays are a flat dollar fee, unlike the coinsurance percentage of traditional Medicare. Some types of plans charge higher copays to see providers out of your network.
Each year, plans establish the amounts they charge for premiums, deductibles and services. Each Part C plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities or suppliers that belong to the plan for non-emergency or non-urgent care).
These rules can change each year, but what you pay may change only once a year, on January 1. For current Medicare beneficiaries, the maximum out-of-pocket spending limit is $6,700 in 2019. If you use out-of-network providers, the limit may be higher. Some plans offer an out-of-pocket limit below the $6,700 maximum.
What are the costs of Special Needs Plans (SNPs)?
Special Needs Plans (SNPs) are Part C plans for people with Medicare who:
- Have certain serious chronic medical conditions, or
- People who have Medicaid and Medicare, or
- People who live:
- In certain nursing homes or
- At home but have high care needs and could qualify for a nursing home.
If you have both Medicare and Medicaid, most of your costs will be covered by those programs. If you don’t have Medicaid or get help from other programs (such as Medicare Savings Programs), your costs may be similar to what you would pay in a regular Medicare Advantage plan.
What is Medicare Part C coverage for inpatient care?
Under Original Medicare, inpatient care is generally covered by Medicare Part A. Medicare Part C covers the same benefits as Medicare Part A including:
- Inpatient care in a hospital
- Inpatient skilled nursing facility care
- Home health care
Medicare Part C may have different cost sharing amounts for inpatient care and home health care than Original Medicare has. With Medicare Advantage, your hospice care benefits will still be covered by Original Medicare.
What is Medicare Part C coverage for outpatient care?
Under Original Medicare, outpatient care is generally covered by Medicare Part B. Outpatient care includes medically necessary services and preventive services to prevent or detect disease. Medicare Part C covers the same benefits as Medicare Part B including:
- Doctor visits (primary care doctor and specialists)
- Laboratory tests and X-rays
- Ambulance services in an emergency
- Both inpatient and outpatient mental health services
- Durable medical equipment such as walkers and wheelchairs
- Preventative tests and vaccines, including flu shots
- Physical therapy
- Occupational therapy
- Speech and language pathology
Medicare Part C may have different cost sharing amounts for outpatient care than Original Medicare has.
What is Medicare Part C coverage for extra benefits?
Unlike Original Medicare, Medicare Part C generally offers coverage for prescription drugs you take at home. The exact prescription drugs that are covered are listed in the plan’s formulary. Formularies may vary from plan to plan.
Other extra benefits that Medicare Part C may cover include:
- Routine dental care including cleanings, x-rays, and dentures
- Routine vision care including contacts and eyeglasses
- Routine hearing care including hearing aids
- Fitness benefits including exercise classes
Not all Medicare Part C plans cover extra benefits in the same way. For example, some Medicare Part C plans may only cover “Medicare-covered dental benefits” which generally only means dental care in the event of an accident or disease of the jaw. If your Medicare Part C covers dental benefits more extensively, you may have a higher monthly premium for that coverage.
What should I do if my Medicare Part C plan doesn’t cover something I need?
If you are denied coverage for something you need, the first thing you may be able to do is file an appeal. You can appeal for a health care service, supply, item, or prescription drug that you think you should be able to get or that you already got. You also can appeal to pay less than you originally were requested to pay.
If your appeal is denied or if you have other frustrations with your plan, you can switch Medicare Advantage plans during the Annual Election Period (AEP) which is October 15 – December 7 every year.