Medicare Advantage is also known as Part C of Medicare. It is administered by private insurance companies certified by Medicare. If you choose to join a Medicare Advantage Plan, it must provide at least all services that are provided by Original Medicare – Part A and Part B. Part C may offer extra coverage, such as vision, hearing, dental, health, and wellness programs, but in general, most Part C plans include Medicare prescription drug coverage, known as Part D, as an extra benefit.
Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services
Medicare Advantage coverage for inpatient care, in general, is covered by Medicare Part A. Regarding Part C, it covers the same services as Medicare Part A, including inpatient hospital care and inpatient care in a skilled nursing facility. Part C also covers Home health care, but hospice care benefits remain under Original Medicare (Part A and B).
As for coverage for outpatient care, which is covered by Part B in general, Part C covers the same benefits as Part B, including visits to primary care doctors or specialists, tests and x-rays, emergency ambulance services, mental health services (both inpatient and outpatient), durable medical equipment, vaccines, physical or occupational therapies, and speech and language pathology.
There are a few extra benefits that Medicare Part C covers, but Original Medicare does not. Some of the services that Part C may include as extra benefits are: Routine dental, vision, and hearing care (including x-rays, dentures, contacts and eyeglasses, and hearing aids), Fitness benefits such as exercise class or something like (SilverSneakers membership), Emergency medical assistance while outside the U.S. And allowance to buy health care products. But not all Medicare Part C plans cover these extra benefits, as well as they are not limited to only named possible benefits.
The main qualification for Medicare Advantage plans is that you already have been enrolled in Original Medicare (Parts A and B) and that you live in the network area of the Part C provider you are considering applying to. Since 2021, people diagnosed with End Stage Renal Disease (ESRD) are also eligible to enroll in almost every Medicare Advantage plan, which was not the case before so most plans would not accept you with diagnosed ESRD.
Of course, the same criteria for Original Medicare are applied to Part C as well. So firstly you need to be a U.S. Citizen or a permanent resident of the United States for 5 years in a row, and you need to reside for six months each year in the plan`s service area.
MEDICARE PART C COSTS
There is a wide range of plan costs. Many people choose low-cost or free plans, and $0 Medicare Part C plans are available in 49 states. On the other side, some plans can cost several hundred dollars per month. Expensive plans usually provide better benefits such as a broader network of medical providers, more coverage for specialized care, or better cost-sharing benefits.
Medicare Part C costs are determined by several factors, such as premiums, deductibles, copayments, and coinsurance. These amounts can range from $0 to hundreds of dollars for monthly premiums and yearly deductibles. But most of your Part C costs will be determined by your chosen plan. Here below are some of the most common factors affecting Part C plan cost:
- Premiums: Some Medicare Part C plans are free, meaning they don’t have a monthly premium. But even if it is a $0 premium, you may still owe the Part B premium.
- Deductibles: Most Medicare Part C plans have both a plan deductible and a drug deductible. Some of the free Medicare Advantage plans offer a $0 plan deductible.
- Copayments and coinsurance: Copayments are amounts you will owe for every doctor’s visit or prescription drug refill. Coinsurance amounts are any percentage of services you must pay out of pocket after your deductible has been met.
- Plan type: The type of plan you choose can also have an impact on how much your Part C plan may cost.
- Out-of-pocket maximum: One advantage of Medicare Part C is that all plans have an out-of-pocket maximum.
- Lifestyle. Most Medicare Advantage plans are location-based because they depend on the provider`s network. This means that if you travel often, you may find yourself stuck with out-of-town medical bills.
- Income. Your yearly gross income can also factor into how much you will pay for your Medicare Part C costs.
MEDICARE ADVANTAGE PLANS
There are two main types of Part C plans on the market: Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans. Besides that two plans, there are Private Fee-for-Service Plans (PFFS) and Special Needs Plans (SNP).
To apply for the HMO plan, you must be an Original Medicare beneficiary. If you are, then you are eligible to enroll in a Medicare Advantage HMO plan in your state. All Medicare Advantage HMO plans must have coverage for hospital and medical insurance, or to be exact they must cover Part A and B services. But most HMO plans also include Part D (prescription drug coverage), dental, vision, and hearing services, and some additional health coverage such are fitness membership or home meal delivery.
HMO plans provide health care coverage from doctors, other health care providers, or hospitals in the plan’s network. Simply, it means that you are given a list of in-network providers to choose from when you need medical services. If you decide to select a provider who is out of network, you may owe a higher cost or the full out-of-pocket amount for those services.
Some features of an HMO plan include a small network of providers to choose from, less paperwork than other plans, and required referrals from your primary care physician in order to see a specialist.
Medicare Advantage HMO plans may have their own monthly premium unless they are premium-free plans. They generally have their own in-network deductible amounts, which can start as low as $0. HMO plans have different copayment amounts for Primary care doctor and specialist visits (it can range from $0 to $50 per visit). After the yearly plan deductible has been met, usually you will pay 20% of the Medicare-approved costs for the services you receive.
The main benefit of the Medicare Part C HMO plan is simplicity, meaning that you only have to manage one plan instead of a few or many of them. In addition to that, a Medicare Advantage HMO plan also controls how much of your own money you have to spend (known as an “out-of-pocket” expense). HMO plans, unlike Original Medicare, have out-of-pocket maximums, meaning that you will spend only a certain amount of money before the insurance company covers the rest of the expense.
PPOs are the most popular Medicare Advantage plan types among beneficiaries. This type of plan allows a greater level of freedom for buyers because, with it, you can go to your preferred doctors, specialists, and healthcare facilities, whether or not they are in your plan’s network. Also, a huge advantage of PPO plans is that you do not need a doctor`s referral to visit a specialist. But be aware that these kinds of plans do charge different rates based on a list of in-network or out-of-network providers.
PPO plans can charge their own monthly premium (Part B premium excluded). They can charge a deductible amount for both the plan, as well as the prescription drug portion of the plan (it depends entirely on the plan you choose). Copayment amounts can differ based on whether you visit a doctor or specialist that is in-network or out-of-network (common copayment amounts range from $0 – $50). Regarding the out-of-pocket maximum, with a Medicare PPO plan, you will have both an in-network maximum amount and an out-of-network maximum amount.
PPO plans are an excellent choice for people who want to keep flexibility in the providers they visit, especially those who want to keep their current doctor. One more advantage of this type of plan is if you need services from a specialist, a referral from a primary care doctor is not required – and you can even save money by using in-network specialists, if possible. On the other side, PPO plans can make your healthcare costs scale quickly regarding the usage of out-of-network services and multiple out-of-pocket maximum amounts.
PFFS Plans has a contracted network of providers, so you can see a list of the network providers who have agreed to always treat PFFS plan members. If you go to a doctor, other health care provider, facility, or supplier who is not on the plan’s network for non-emergency or non-urgent care services, your plan may not cover your services, or your costs could be higher. Some PFFS plans include prescriptions for drugs, but if not you can always join Medicare Part D to get the drug coverage you need. The advantages of this type of plan are that you do not need to have primary care doctor and you do not need to get a referral from a primary care doctor to see the specialist.
Medicare Advantage SNP plans limit membership to people with specific diseases or characteristics. SNP plans adjust their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. They almost always have specialists for the diseases or conditions diagnosed with beneficiaries. The great advantage of this kind of plan is that all SNP plans provide drug coverage (Medicare Part D). On the other hand, you are required to have a primary care doctor, as well as have a referral from him/her if you need to see a specialist (excluding yearly screening mammograms and yearly pap tests, and pelvic exams).
SNP plans are meant for people who live in certain institutions (like nursing homes) or who live in the community but require nursing care at home, for people who are eligible for both Medicare and Medicaid, and for people who have specific chronic or disabling conditions (diabetes, ESRD, HIV/AIDS, chronic heart failure, or dementia). People who met these criteria can join an SNP at any time.