Medicare Part C is health insurance coverage from a private insurance company that assumes your risk from Original Medicare. This means that Medicare Part C plans become your primary source of coverage rather than Medicare Part A and Part B.
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Medicare Part C plans are also known as Medicare Advantage plans. These policies can offer an array of benefits and may vary from carrier to carrier or from zip code to zip code.
What is Medicare Part C?
Original Medicare is made up of Medicare Part A (hospital services) and Part B (outpatient services). Medicare Part C plans are all-in-one healthcare options that combine Original Medicare benefits plus additional coverage in some cases.
When you enroll in a Medicare Part C plan, the company you enroll with becomes your primary source of health insurance.
Medicare Part C coverage must at least match Original Medicare coverage. However, since there are several Medicare Part C plan types, costs for enrollees can vary widely.
Types of Medicare Part C Plans:
- Health Maintenance Organization – HMO plans offer beneficiaries care from a network of doctors and hospitals for a set fee per service. Typically, you will not receive coverage outside of this network and referrals are necessary to see specialists.
- Preferred Provider Organization– PPO plans offer coverage from a network of providers as well as out-of-network doctors and hospitals for a higher cost. When seeing a provider out of network, you will still receive coverage but be responsible for higher cost-sharing.
- Health Maintenance Organization Point of Service – HMO POS plans allow beneficiaries to have the low cost of an HMO plan and the ease of a PPO plan with out-of-network coverage.
- Private Fee for Service – PFFS plans offer coverage at a fixed rate for each medical service. Doctors are able to accept or deny these fixed rates for some services but not for others.
- Medicare Advantage Special Needs – Special Needs Plans provide specific benefits for individuals with certain conditions. There are Special Needs plans for conditions such as diabetes, cancer, ESRD, etc.
Medicare Part C Eligibility
To be eligible for Medicare Part C you must:
- Enroll in Medicare Part A
- Enroll in Medicare Part B
- Live in the service area of your selected plan
- Have a valid Medicare Advantage Enrollment Period.
To enroll in a Medicare Part C plan, there are no health questions, and you cannot be denied coverage for any reason.
After January 1, 2021, even those with end-stage renal disease (ESRD) are eligible for any Medicare Part C plan in their area. Prior to 2021, those diagnosed with ESRD were only eligible for Special Needs Plans. Now, those with ESRD are eligible for a broader range of plans with different coverage options.
How Much Does Medicare Part C Cost?
Costs for Medicare Part C differ per plan. Thus, it is difficult to predetermine your total out-of-pocket costs for the year.
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Several Medicare Part C plans have a low monthly premium, which makes it easy to understand why many people enroll in this type of coverage. However, Medicare Part C plans often come with additional costs for which the beneficiary should budget. Even with all the perks, there are downfalls to Medicare Advantage.
In addition to your Medicare Part C premium, you will be responsible for covering the Medicare Part C deductible, copayments, and coinsurance for your selected plan.
On every Medicare Part C plan, you will have a cap on yearly out-of-pocket expenses. This is known as the maximum out-of-pocket limit (MOOP). It is important to understand your maximum out-of-pocket limit as it can reach $10,000 or higher for out-of-network costs.
What Medicare Part C Plans are Available?
Medicare Part C plans are available through major health insurance companies as well as regional carriers depending on your location. Some of the most popular Medicare Part C carriers include:
- UnitedHealthcare
- Cigna
- Aetna
- Humana
- Blue Cross Blue Shield
- Kaiser
- Wellcare
Each of these carriers offers different plans with varying benefits. However, the most popular Medicare Part C plan types are HMO and PPO plans.
Thus, if you are looking for a plan with a wider availability of doctors and hospitals, you might need to look at PPO plans. If you are looking for a smaller network of providers, an HMO plan might be right for you. Often, PPO plans come at a higher cost because they allow more benefits than an HMO plan.
To know which plan types is right for you, it is important to research the available plans in your area to know what benefits will best fit your needs.
Medicare Part C FAQs
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How to Enroll in Medicare Part C
At MedicareFAQ, we help Medicare beneficiaries enroll in coverage every day. One of our licensed insurance agents will explain the pros and cons of your options and research all the top providers in your area. Whether it be a Medicare Part C or Medicare Supplement plan, we work to ensure our clients end up with the best policy for their healthcare needs.
Once you connect with a licensed agent, they begin a free needs analysis to determine which Medicare plan type is right for you. Then, you can compare all of the top carriers in real-time to determine your best option.
To work with a licensed Medicare expert, give us a call at the number above. Can’t call now? No problem! Complete our online rate form to get the process started today.
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Sources:
MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.
- What is Medicare Part C, HHS. Accessed April 2022.
https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-c/index.html - How Do Medicare Advantage Plans Work, Medicare. Accessed April 2022.
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/how-do-medicare-advantage-plans-work - Understanding Medicare Advantage, Medicare. Accessed April 2022.
https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf
My wife is on Medicare, retired, no major health issues. She has coverage through AARP. We are trying to find one that will give back the $148 taken from her check. Losing the $148 is a hardship. We live in Florida, where no Medicaid is to pay for the cost.
Hi Rhonda! It depends on your zip code. The give-back benefit is only available in some areas.
Hi, I am looking into medical benefits on behalf of a loved one. They have Rheumatoid Arthritis and require what most insurances classify as “specialty” medication. Due to this classification Medicare, and their supplemental plans will not cover the RX to a reasonable amount. By reasonable I mean typically affordable for an average individual. The base price of a months supply for the prescription in question is around 6,000 dollars. With their current plan my loved one would still end up paying over $1,500 a month for their medicine. Which is impossible when she is living off of $1,000 a month. My question is what kind of drug coverage can be found using an Advantage plan? Would it be worth it to have her look into this?
Hi Dayna! You can use the Medicare plan comparison tool to type in the medication and see what Medicare Advantage plans will cover it. It will also show you other Part D plans that may cover it. There is a donut hole with Part D.
will i still qualify for the part B give back option if i qualify for the extra help from medicare?
Hi Oscar! As long as you don’t have a Medicare Savings Program that helps you pay the Part B deductible, you will qualify. I don’t believe Extra Help will make you ineligible.
If I 144% under poverty level l got a letter from extra help it says 50 % of symubsidy to help pay for monthly premiums what does that mean will they reduce my Medicare part b by 50% from my check please explain don’t undedstand
Lindsay:
We are located in California. How much does Medicare pay out for a Senior Citizen on their Medicare Advantage plan. Is it taken out of the Senior’s Social Security Benefit?
Hi Steven! It depends on your zipcode and the carrier you choose to enroll with. You can read more about the Part B give-back benefit here.
Hi Lindsay,
Can you tell me if a Medicare Advantage has the authority to request prior authorization for services covered under an NCD-CED?
Thank you,
Lori
Hi Lori. I would imagine the carrier does have the authority to request prior authorization. You can read more on CMS coverage with evidence development.
I have a question. Does medicine pay a premium for those using an advantage plan? My understanding is that Medicare pays a premium to insurance companies for administering advantage plans so the cost is higher then go conventional Medicare
Hi Richard! Medicare does pay the Medicare Advantage carrier to take on your risk. However, you still must pay the monthly premium for Part B. Some Medicare Advantage plans come with a premium reduction benefit to help with this.