Medicare Part C (Advantage Plan)

Medicare Part C goes by several different names, which adds to the confusion people feel when confronted with Medicare decisions. Part C can be called a Medicare Advantage Plan or an MA Plan. These are HMO, PPO, PFFS, SNP, HMOPOS, and MSA insurance plans which are offered by private health insurance companies which are approved by Medicare. They allow you some choice in coverage. You have the option of choosing a Medicare Advantage Plan to take the place of both your Medicare Plan A and Medicare Plan B coverage. One of the benefits is that many MA Plans also include other coverage, such as vision, dental, hearing, and prescription drug coverage.

Basically, Medicare has a set amount they will pay for you coverage each month. You pay the remaining amount on the plan you choose. Approved insurance companies must follow certain rules. They are also free to set the plan's coverage, premium amounts, deductibles, copayment amounts, coinsurance amounts, annual limits for coverage, and more.

Medicare Part C Coverage

MA plans are required to cover the same types of services that original Medicare covers, except for hospice care. This is because your hospice care is covered by original Medicare even if you have joined a Part C plan as well. In addition to the coverage you receive that is the same as Part A and Part B coverage from original Medicare, Medicare Advantage Plans often cover additional healthcare areas, such as hearing, vision, dental, health and wellness and more. Most MA plans also have prescription drugs coverage, similar to Medicare Part D.

Types of Medicare Part C Plans

  • Health Maintenance Organization (HMO)
    This is a very common health insurance structure, in which you receive medical care almost entirely from in-network providers designated by the private insurance company providing your MA plan. You typically need a referral from your primary care physician to see any specialists.
  • Preferred Provider Organization (PPO)
    A PPO Part C plan allows the patient to choose from a list of in-network providers at no extra cost and with no referrals from a primary care doctor. Patients can also choose out-of-network providers for a higher fee.
  • Private Fee-For-Service Plans (PFFS)
    The health care provider you see must agree to the payment terms set forth by your private insurance provider. They can refuse treatment in non-emergency situations if they do not agree to the terms and conditions of your plan. Emergency care is covered even when the provider does not agree to the terms of your plan.
  • Special Needs Plans (SNP)
    An SNP is a health insurance plan that is tailored to fit a specific group of people based on a disease, medical condition, or other characteristic. It can work like an HMO or PPO, depending on the private insurance provider.
  • Health Maintenance Organization Point of Service Plans (HMOPOS)
    Less commonly available, HMOPOS plans combine attributes of HMO and PPO plans in a hybrid option. Because the insurance companies providing Medicare Part C coverage are private companies, these plans may not be offered in all states.
  • Medical Savings Account Plans (MSA)
    This Part C plan is also less common than the first four listed. It combines a health care plan and a savings account. Your allocated Medicare dollars are deposited in the savings account for you to use to cover medical costs during the year. You health care plan has a high deductible amount with MSA plans.

Medicare Part C Costs

There will usually be an added monthly premium in addition to your Medicare Plan B premium amount (2012 standard Part B base premium is $99.90/mo). This additional MA plan premium can vary from plan to plan, because the private insurance company creating the plan rules, rates, and coverage benefits can choose the varying plan options.

When you are considering a Medicare Advantage plan, you will need to read about the specific plan benefits, premiums, deductible requirements, coinsurance amounts, copayments, out-of-pocket annual limits, rules about network providers, and more before choosing the plan that is right for you.

Medicare Part C Enrollment

There is a two-part process to enrolling in Medicare Advantage Plans because you need to enroll with Medicare and you need to apply for the specific insurance plan at the private insurance company.

Enrolling in Medicare Part C can only be done during certain enrollment periods. General enrollment periods (if you miss your initial enrollment period) are every year from January 1st through March 31st. The initial enrollment period for most people comes around the time of their 65th birthday. The three months before the month of your birthday, the month of your birthday, and the three months following your birthday make up your seven month initial enrollment period. For those who are disabled and begin to receive Social Security or Railroad Retirement Board benefits, the initial enrollment period is from the 21st month after starting to receive benefits through the 27th month of receiving benefits.

To apply for the Medicare Part C plan that is right for you, you will need to contact the private insurance company offering the plan via phone or website and submit your application.