What is Part C?

Medicare Part C is also known as a Medicare Advantage plan is offered by private health insurance companies and have a contract with Medicare. Under this plan, beneficiaries can get Medicare Part A and Part B benefits, along with a few additional services.

What are the Added Benefits of Enrolling in Part C?

There are several types of Part C plans available, and a person has to choose a plan that helps them to meet their healthcare needs best. Part C premiums also differ based on the benefits offered. In addition to all the services provided for by Medicare Parts A and B (excluding hospice care), many Part C plans provide extra coverage for routine vision, dental and hearing services as well as wellness programs. Some Part C plans cover certain prescription drugs; this list may differ from plan to plan. Emergency and urgent care services are usually taken care of by all plans.

Does Part C cover Inpatient Care?

Part C offers the same benefits as Part A and covers care for hospitalization as well as receiving care in a nursing facility. In addition to this, home healthcare is typically covered by Part C. However, the rules regarding cost-sharing may differ between Part C and Original Medicare. Hospice care, however, will still be taken care of by Original Medicare.

Does Part C cover Outpatient Care?

Part B usually covers outpatient care on an original Medicare plan. A Part C plan offers the same coverage as Part B including visits to

  1. primary care and specialist doctors
  2. tests at laboratories
  3. X-rays
  4. emergency ambulance services
  5. inpatient and outpatient mental health care
  6. medical equipment such as wheelchairs
  7. tests and vaccines to prevent diseases
  8. physical and occupational therapy
  9. speech and language pathology

However, Part C plans may have different rules about cost-sharing compared to Part B.

How to Become Eligible for Part C?

To become a beneficiary of Part C, you will need to first qualify for Medicare Parts A and B. An exception is made in cases where a person has ESRD or End-Stage Renal Disease. If a person fulfills these qualifications, they are eligible to apply for Part C provided they live in the service area of the Part C plan. In cases where a person is covered by existing health insurance, either through their employer or a union, they need to check with them first before enrolling in Part C to ensure they do not lose their existing coverage once Part C covers their healthcare needs.

What Types of Part C Plans are Available?

Each Part C plan has certain advantages that are designed to suit an individual’s particular needs. One can weigh the pros and cons of each plan and decide on one that works for them.

  1. HMO – Also known as a Health Maintenance Organization plan, this kind of a medical insurance plan offers its beneficiaries a network of doctors and healthcare institutions to choose. Using a service within this network is also cost-effective.
  2. PPO – This is also called a Preferred Provider Organization Plan, and it offers its enrollees greater flexibility in choosing a healthcare service. This means that they can either go to a doctor covered by the network or one outside the network as long as the doctors accept the Medicare rules.
  3. PFFS – A Private Fee-For-Service plan is a plan that decides how much a healthcare provider is paid for treating a patient and how much a patient will pay for the treatment they receive. This requires doctors and healthcare facilities to accept the rules laid out by the plan for the services to be covered.
  4. SNP – This is also called a Special Needs Plan and is designed for those people who have special requirements. The three plans are designed for
    a) People who are on Medicare and live in institutions
    b) People who qualify for dual eligibility to receive Medicare as well as Medicaid
    c) People who suffer from chronic illnesses in the form of diabetes, HIV/AIDS and End-Stage Renal Disease. Prescriptions drugs are usually covered by this plan.
  5. HMO-POS – This is also called a Health Maintenance Organization – Point of Service plan. This plan covers a wide range of services both within and outside their network. However, there is a difference between rates and enrollees often pay less when they use services within the network.
  6. MSA – This plan, also known as a Medical Savings Account plan, is designed with a high deductible and a bank account to help cover the deductible. Every plan decides on how much money is deposited into the account. This money is considered tax-free and is meant to be spent on medical expenses that meet IRS rules, such as the deductible.

What Can you do if a Part C Plan Denies Coverage for a Service?

A person can file an appeal if they believe they should be covered for a particular service, medical item or prescription drug, and their plan doesn’t include it. They can also appeal to lower the costs they are being charged for the same. If the appeal is rejected or a person is unhappy with their plan, they can change their plan when the open enrollment period begins.

What are the Costs Involved in Part C?

Because private insurance companies design and sell Part C plans, the costs can differ. While certain plans have no premiums, others require a monthly premium to be paid by the enrollee. In addition to this, a Part C beneficiary needs to ensure that their Medicare Part B premiums are covered. This is because all Part C beneficiaries are still considered to be enrolled with Medicare Parts A and B. Typically, Part C rules state that enrollees cannot avail of a Medicare Supplement Insurance plan, otherwise known as Medigap, to get financial aid.

When Can You Enroll in Part C?

A person can apply to become a Part C beneficiary only during specific election periods.

Initial Coverage Election Period (ICEP) – When a person first qualifies for Part C or a Medicare Advantage plan, this application period is called an Initial Coverage Election Period (ICEP). It is a period that spreads across seven months—beginning three months before the month they become 65 years of age and ending three months later. If a person who is below this age limit receives Social Security benefits, they become eligible for Medicare 25 months after they start making use of their Social Security benefits. The application for this category also spans seven months—3 months before and three months after the month they become eligible.

Annual Election Period (AEP) – Applications are open from October 15 to November 7 on a yearly basis. The actual coverage of the plan that a person chooses during this period will begin on January 1 of the following year. This period also allows people the flexibility to change or drop their current plans.

Medicare Advantage Disenrollment Period – In case a person who is a beneficiary of a Part C plan decides to go back to traditional Medicare, they can choose to do so within the special disenrollment period, from January 1 to February 14 every year. Once disenrolled prescription drugs are no longer covered, but a beneficiary can add on a separate Medicare Part D prescription drug plan.

Special Election Period (SEP) – Typically, a person who enrolls in a Part C plan has to stay with their plan until the next Annual Election Period begins. However, there are certain exceptions to this rule that qualify a person to make changes to their plan during a “Special Election Period.” A few of these exceptions include:

  1. If a person has to change residence and is moving beyond the service area of their plan
  2. If a person’s circumstances make them eligible to apply for “Extra Help” which helps to cover prescription drugs
  3. If a person needs to have institutional care It is essential to study the different types of Part C plans available in your area well before you enroll in one. Since premiums can differ between plans, it is wise to choose one that covers all your medical needs at an affordable cost.

If you are shopping for a new Medicare Advantage or Part C plan, Koi Healthcare can help.

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