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Choosing Coverage: Is Medicare Part C Right for You?

Exploring your Medicare Advantage (Part C) coverage options

Key Takeaways

  • Medicare Advantage is an “all-in-one” alternative to Original Medicare. It covers Part A, Part B, and usually Part D (prescription drugs).

  • The two most popular choices of plans are Preferred Provider Organization (PPO)A Preferred Provider Organization (PPO) is a health insurance plan that doesn't require you to get a referral from a primary care physician to see other doctors. Most PPOs allow you to see any doctors or providers in their network. and Health Maintenance Organization (HMO).

  • If your provider is in-network,In-network refers to the doctors, hospitals and other providers that are inside of your provider network. This is the group of providers that has agreed with your health insurance company to treat its customers. you can save money and gain additional health and wellness benefits.

  • You can enroll in Medicare Advantage during any of the Medicare enrollment periods. If you’re in the Initial Enrollment Period,The initial enrollment period is a seven-month enrollment period when individuals, who are not automatically enrolled in Medicare, can sign up for Parts A and B. The period begins three months before your 65th birthday month, includes your birthday month, and continues for three months following your 65th birthday month. you must have joined Part A and Part B before selecting a Medicare Advantage plan.

Are you having trouble choosing the best coverage? Let’s review the Medicare Advantage (Part C) coverage.

What’s Covered by Medicare Advantage Compared to Original Medicare

It can be hard to understand the differences between Original Medicare (Parts A and B)Original Medicare (Parts A and B) is fee-for-service health insurance available to all Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). and Medicare Advantage (Part C) coverage. Even though Part C is separate from the Original Medicare plan, it doesn’t have less coverage than Parts A and B. The plan can give you comprehensive coverage and save you money if it fits your lifestyle. However, it’s not as flexible as Original Medicare. 

Think of Medicare Advantage as a bundle of Parts A, B and usually D (prescription drugs).Medicare Prescription Drug Plan (Part D) is prescription drug coverage for people enrolled in Medicare. Part D is optional and is offered by private insurance companies. Most plans also have health and wellness benefits (like access to gyms and nutritionists) and dental and vision coverage. You can still join a Medicare Advantage plan even if you have pre-existing conditions,A pre-existing condition is an illness, injury or other medical condition you had before you enrolled in your health insurance policy. except for end-stage renal disease (ESRD).

Original Medicare 

  • Hospital coverage (Part A)
  • Medicare coverage (Part B)

Medicare Advantage 

  • Hospital coverage (Part A)
  • Medicare Coverage (Part B)
  • Certain plans also include: routine dental, hearing and vision, prescription and over-the-counter drugs, fitness trackers, gym memberships, transportation to doctor visits, telehealth (virtual visits), pest control, food for service animal, acupuncture and nutritionist sessions.

Why is Medicare Part C Separate?

Medicare Advantage (Part C) is still part of Medicare and has PPO and HMO options, but the government does not administer it. You have Medicare rights and protections, even though private insurance companies manage your benefits. Medicare Advantage helps fill some of the gaps from Original Medicare, but you can’t add Supplemental CoverageMedicare Supplement Insurance (Medigap) are policies designed to provide coverage that Original Medicare (Parts A and B) do not. Medigap policies are purchased in addition to Original Medicare and have their own monthly premiums you'll need to pay. with Part C.

Does Medicare Part C Have a Required Provider Network?

Medicare Advantage Plans aren’t as flexible as Original Medicare policies. Many plans only cover costs if you visit providers within their network. Health Maintenance Organization (HMO) plans generally offer narrower primary care networks, while Preferred Provider (PPO) plans are broader. [1]

What are the Different Types of Medicare Part C Plans?

Medicare Advantage (Part C) offers different service options and on a state-by-state basis. First, let’s take a look at the two most popular choices:

Preferred Provider Organization (PPO) 

  • All Part C plans have a provider network, but PPO offers the flexibility to visit an out-of-networkOut-of-network refers to doctors, hospitals and other providers that do not have an agreement to treat your health insurance company's clients. Visiting an out-of-network provider typically means more out-of-pocket costs and less coverage. provider that accepts Medicare. 
  • In-network providers are affordable.
  • You are not required to choose a primary care doctor.A Primary Care Physician is a doctor that oversees and monitors your medical care under some plan types. PCPs also may be responsible for referrals to specialists.

Health Maintenance Organization (HMO)

  • You must see an in-network provider unless you need emergency care.
  • Choosing a primary care doctor is a requirement.
  • Plans may require a referral or prior authorization for specialists, and some tests and procedures.
  • Most plans include prescription drug coverage (Part D).

Additional Part C plans include:

  • Special Needs Plans (SNPs)
  • Medicare Medical Savings Account (MSA) plans
  • Private Fee-for-Service (PFFS) plans

FAQs

I travel frequently. Can I get coverage when I travel without additional costs?

Medicare Advantage plans and Original Medicare don’t cover care outside of the United States. Consider looking at a Medigap policy if you need coverage in other countries. As for traveling state-to-state, Medicare Advantage plans usually don’t cover non-emergency care if you go outside of your plan’s network.

Can I keep my Medicare Advantage Plan if I have End-Stage Renal Disease (ESRD)?

You can have a Medicare Advantage Plan with ESRD if you meet the following criteria: 

  • You develop ESRD after you’ve already enrolled in a Medicare Advantage Plan
  • You no longer have ESRD after treatment
  • You join a Medicare Special Needs Plan (SNP) that covers ESRD
  • Your Medicare Advantage Plan leaves Medicare or no longer provides coverage in your area 

It’s important to note, people with ESRD will be allowed to join Medicare Advantage Plans without restrictions starting in January 2021.

Does each Medicare Advantage plan provide the same coverage?

The short answer is no. Although Medicare Advantage plans must cover at least the Medicare “Medically-Necessary Services,” Medicare Advantage Plans can charge different deductibles, offer co-payments (for instance $30 per office visit), or various co-insurance terms (such as 20% of the procedure cost). Some Medicare Advantage plans have a limit on how much you can spend in a year.

What's Next?