Medicare Advantage Plans, also known as Part C, are private insurance programs like health maintenance organizations (HMOs) or preferred provider organizations (PPOs). Private insurance companies approved by Medicare provide Part C coverage.
In Original Medicare (only Medicare Hospital Insurance (Part A) and Medicare Medical Insurance (Part B)), also known as traditional Medicare, people can use any doctor or hospital participating in the Medicare program. Under Part C, when people join a Medicare Advantage Plan, coverage is limited to care within the plan’s network of doctors and hospitals. If they go outside the plan network, they may be faced with higher co-payments or responsibility for the full bill.
Part C offers additional benefits not available in traditional fee-for-service (FFS) Medicare. This may include routine dental care, eye examinations and glasses, and prescription drug coverage.
Part C must cover all the same services Original Medicare covers, except for hospice services. People are still in the Medicare program. Hospice services are paid by Original Medicare when people enroll in a Medicare-approved hospice program, not their Medicare Advantage Plan.
People will use a card issued by their Part C provider to get their Medicare-covered services. However, people should not throw away their red, white and blue Medicare card, but keep it for future use, in case they leave their Part C plan. Part C is responsible for all of a member’s health care needs, as well as all of their claims and/or bills. In other words, Part C will process all of the member’s claims for consideration, not Original Medicare (unless the member has a Cost Plan). People should contact their Part C provider for any claims questions.
Most Part C plans offer prescription drug coverage:
• People may not be enrolled in a stand-alone Medicare Prescription Drug Plan (Part D) and in Part C at the same time, unless they have a Medical Savings Account (MSA), Private Fee-for-Service (PFFS), or Cost Plan.
Costs, extra benefits and rules vary by plan:
• Some out-of-pocket costs may be higher in one plan than another.
• People may have to pay an extra monthly premium in addition to their monthly Part B premium. It is very important to note that people are still responsible for their Part B premium.
• If people join a Part C plan, they will not need, and cannot buy, a Medicare Supplement Insurance (Medigap) policy. If they already have a Medigap policy, they can keep it, but Medigap will not pay for any plan costs, such as co-payments.
People are only able to join or leave Part C at certain times.
• They must have Part A and Part B to join.
• They can join Part C even if they have a pre-existing condition, except for end-stage renal disease (ESRD). Medicare beneficiaries with ESRD usually cannot join Part C.
People can join, switch or drop Part C at these times:
Initial Enrollment Period: when people first become eligible for Medicare (the seven-month period that begins three months before the month they turn age 65, including the month they turn age 65, and ending three months after the month they turn age 65). The Annual Enrollment Period is between Oct. 15 and Dec. 7 of each year. Coverage will begin on Jan. 1 of the following year.
Open Enrollment Period: between Jan. 1 and March 31 of each year. Coverage will begin the first day of the month after the plan receives the person's enrollment form. During this period, people cannot do the following:
• Switch to or join a plan with prescription drug coverage unless they already have Part D.
• Drop a plan with prescription drug coverage.
• Join, switch or drop an MSA Plan.
Special Enrollment Periods: In most cases, people must stay enrolled for that calendar year, starting the date their coverage begins. However, in certain situations, they may be able to join, switch or drop Part C at other times. These situations include the following:
• If they move out of their plan's service area.
• If they have both Medicare and Medicaid.
• If they qualify for Extra Help/Low-Income Subsidy to pay for their prescription drug costs.
• If they live in an institution (like a nursing home).
• If someone gets Medicare due to a disability, he or she can join during the period that is from three months before to three months after the 25th month of disability. The person will have another chance to join during the period starting three months before the month they turn age 65 and ending three months after the month they turn age 65.
RELATED FAQs
What Will Happen to Members of Medicare Advantage Plans (Part C) Under the Affordable Care Act (ACA)?
What Year Were Medicare Advantage Plans (Part C) Established?
How Are Payments to Medicare Advantage Plans (Part C) Calculated?
