What Is Medicare Part C?
Medicare Part C is an all-in-one insurance known as the Advantage Plan.
In order to explain this, a basic understanding of regular Medicare will help, which I'll cover first. There are pros and cons that you need to compare. I'll review that in the last section.
- First — A Review of Regular Medicare
- Medicare Part C: The Advantage Plan
- Advantage Plan Benefits
- Common Medicare Benefits
- Other Coverages Provided by Advantage Plans
- Prior Authorization and Referral Requirements
- You Still Need Medicare Parts A and B
- The Advantage Member Card
- Is Medicare Advantage Right for You?
First — A Review of Regular Medicare
Parts A and B
Regular Medicare has two primary parts. Part A covers hospital expenses. Part B covers doctors and other medical procedures. Both of these combined pay for 80% of your healthcare costs.
You still pay the deductible and you are responsible for the other 20%. However, that’s 20% of what Medicare approves for the billing, not 20% of what the doctor or hospital charged. Not many people realize that.
If you are concerned about paying your share, you can get an optional supplemental plan that pays the 20% portion that Medicare doesn’t cover, less the deductible. This is also known as Medigap. These plans are provided by independent insurance companies.1
There are several different supplemental plans to choose from, labeled as Plans A through N, each with different coverage benefits and premiums. However, that’s not the subject of this article.
Besides a supplemental plan, you need to consider prescription drug coverage. This is Part D. You need to subscribe to this with an independent insurance company. Each one has somewhat different coverages for various drugs.2
Part D is optional, but there is a penalty of you don’t take it. Don’t confuse that with the penalty for Obamacare, which President Trump repealed. The penalty for not having Medicare Part D still exists.
If you don’t have Part D coverage or a Medicare approved alternative after your 65thbirthday, then a penalty will be added to your Part D premium when and if you ever decide you need it.
The penalty is an accumulative amount of 1% per month. That means if you skip two years (24 months) and then sign up for a pharmaceutical plan, you’ll pay a penalty of 24% on top of the regular Part D premium. Technically that percentage is figured on the average nationwide Part D premium, not on the premium of the plan you choose.
Now that I gave you a limited explanation of regular Medicare, you’re ready for me to describe Part C.
Medicare Part C: The Advantage Plan
It’s inaccurate to call this Part C in my opinion. It always confuses people because it’s not really a part of Medicare. It’s a plan, an Advantage Plan, and it completely replaces regular Medicare.3
Most advantage plans are health maintenance organizations or preferred provider organizations. They cover the same medical services as original Medicare parts A and B. In addition, they provide additional benefits that I’ll discuss below.
A Medicare Advantage plan takes over the entire record keeping. This actually simplifies things. Even Medicare Part D is handled by most advantage plans. You still need to pay for Medicare Part B or have that deducted from your Social Security payments.
The Advantage plan premium can also be deducted from Social Security if you prefer. These premiums are usually much lower because Medicare reimburses those private insurance companies for taking care of everything. Some advantage plans even have a zero premium!
In the rest of this article I’m going to give you a general outline of the coverage and benefits. I can’t go into details because each advantage plan in every town or city offers different benefits.
For example, the advantage plan I have pays $200 a year towards eyeglasses or contact lenses and $50 a month towards gym membership. However, they are only in New York, so you need to review the plans available to you where youlive.
Once you have the basic understanding that I’ll explain below, you’ll have the knowledge required to do your own research into the plans available in your area. You’ll even know if a Medicare Advantage plan is, or isn’t, a better choice over regular Medicare for your situation.
Your Maximum Out-of-Pocket Responsibility
There is a limit to how much you would have to pay with accumulated co-pays per year. As long as you go to in-network providers, once you reach that annual limit, you no longer need to pay the co-pays.
That limit is high, however, usually in the range of $7,000. However, if you are in poor health and go to doctors or the hospital often, your co-pays can add up. It’s nice to know there is a limit to your out-of-pocket expenses.
Do I Still Pay the Deductible?
The standard Medicare deductible is paid by some advantage plans, so you may have no deductible. Regular Medicare doesn’t pay until the deductible is used up.
Advantage Plan Benefits
Every plan is different, but I suggest looking for these common benefits:
- Zero co-pay for Preventive Care
- Low or zero co-pay for PCP office visits
- Zero co-pay for tier-1 generic drugs
Advantage Plan Reimbursements
Many Medicare Advantage plans provide reimbursement for certain things not usually covered by regular Medicare. Here are things to look for, based on what you prefer having:
- Allowance for OTC pharmacy items
- Gym membership reimbursement
- Eyeglass / contact lens reimbursement
Prescription Drugs Benefits
Most Advantage plans include Part D coverage. They are arranged in a tier structure. There are many generic drugs in tier 1, which has a low of zero co-pay, but other drugs fall into higher co-pay tiers.
If you are taking a variety of medications, check with each plan to see how you are covered. Every plan has different co-pays and they each place drugs in a different tier structure.
Some plans offer zero co-pay when certain drugs or ordered through the mail.
You also need to watch out for charges if you order drugs from out-of-network providers.
If your familiar with the way Medicare handles drug coverage when you enter the Coverage Gap (also known as the Donut Hole), and if you fall into this situation as a general rule, then you will want to check on how your available advantage plans handle this. Each plan has their own unique way that they handle Gap Coverage.
All advantage plans have their own structure for hospital costs, and it may be different for inpatient and outpatient.
Some plans have reasonable daily co-pays for the first week. Then you are fully covered and pay nothing up to three months. That’s great for those who are generally healthy.
If you are one who expects to have very long hospital stays, then you might be better off considering regular Medicare and even paying for an additional supplemental plan rather than an advantage plan.
If you use any of the following preventive services, confirm if it’s covered by your plan. Most advantage plans have a zero co-pay for these services.
- Yearly "Wellness" visit
- Abdominal aortic aneurysm screening
- Alcohol misuse counseling
- Bone mass measurement
- Depression screening
- Diabetes screening
- Cardiovascular disease screenings
- Colonoscopy and Sigmoidoscopy
- Mammogram breast cancer screening
- Cervical and vaginal cancer screening
- STD and HIV screening and counseling
- Medical nutrition therapy services
- Obesity screening and counseling
- Prostate cancer screenings (PSA)
- Stop smoking tobacco counseling
- Flu, Hepatitis B, and Pneumococcal Vaccines
Regular Medicare does not pay for dental work, but some advantage plans cover dental x-rays, one oral exam every year, and two cleanings every year. Check with the plans in your area.
Common Medicare Benefits
All benefits common to Medicare are included with advantage plans. Below is a summary of these benefits. Under an advantage plan the co-pays and limits might be better than regular Medicare coverage. You need to confirm this with the plans available in your area.
Routine eye exams and follow up visits to diagnose and treat eye diseases and conditions are standard.
In addition, some plans include coverage for contact lens or eyeglass prescriptions. Some plans even reimburse part of the cost of filling these prescriptions.
All advantage plans cover emergency care when you need to a hospital ER. There is usually a higher co-pay, such as around $80.
Medicare covered exams to diagnose and treat hearing issues and routine hearing exams are included. Usually one visit per year, but evaluation and fitting for hearing aids might be covered just once every other year.
Other Coverages Provided by Advantage Plans
Many advantage plans also include the following. Check with the plan you are considering:
- Skilled Nursing Facilities
- Occupational therapy
- Physical therapy
- Cardiac Rehabilitation Services
- Ambulance Services
- Foot Care (Podiatry)
- Medical Equipment and Supplies
- Chiropractic (if Medicare approved)
- Outpatient Surgery
- Mental Health Services
- Medicare-certified hospice
Prior Authorization and Referral Requirements
Some procedures require prior authorization by your doctor and in some cases you need a referral from your primary doctor to go to a specialist. However, there are exceptions, so check with the plan you are investigating.
You Still Need Medicare Parts A and B
When you have an advantage plan, you still need to pay the premium for Medicare Part B (Medical Coverage).
If you’re over 65 but had health coverage through your employer or your spouse’s employer, and you now need to enroll in Medicare, keep in mind that if you select to go with an advantage plan (Part C) then you still need to sign up for Medicare Parts A and B.
The Advantage Member Card
You only need to carry one card to show when you receive services—your Medicare Advantage member card. You do not need to carry your regular Medicare card. Put that away in a safe place. You don’t need it unless you go back to regular Medicare.
If you use regular Medicare and have Part D for prescription drug coverage and a supplemental plan to cover the other 20%, then you would be carrying three cards with you. I did that the first year I was on Medicare, before I started using advantage plans.
Is Medicare Advantage Right for You?
So what's the catch? Whenever something sounds too good to be true, it’s important to be aware of the negatives of Medicare Advantage plans.
With regular Medicare you can go to any doctor that accepts Medicare. You’re covered when you travel too.
Advantage plans, on the other hand, have a network of doctors, hospitals, and pharmacies in your area. If you use providers that are not in the network, the plan may not pay for those services.
You must use pharmacies that are in the network to fill your prescriptions for covered Part D drugs. Most standard pharmacies are included, but you should check on that.
You need to verify that the doctors you go to are in the network for the plan you are interested in using. They all list the in-network doctors online so it’s easy to research.
In addition, doctors can be added or drop off the plan any time–even in the middle of the year. That means you may have to change doctors. This is rare and never happened to me, but it can happen.
You can change to a different advantage plan only once a year, during the open enrollment period at the end of the year.
If you move, you would have to select a new plan that covers your new location. This special enrollment period allows making this change anytime, but only under the condition that you were moving.
Benefits can be added or eliminated upon the annual renewal. You will know that ahead of time so that you can make a decision to switch to another advantage plan, or back to regular Medicare, during the open enrollment period.
My prior advantage plan had discontinued reimbursing for OTC essentials the following year. So during the open enrollment period I switched to an advantage plan with another insurance company that still offered that benefit.
If you travel a lot, you’ll want to be sure you can go to any doctor that accepts Medicare no matter where you are. In that case, an advantage plan is not a good choice for you.
Besides all that, I am comfortable with my advantage plan. It gives me everything I need plus other benefits I decided to take advantage of, such as gym membership and eyeglass reimbursement.
It all boils down to what your needs are, the level of your health, and the selection of plans available in your area. You have to decide if it’s an advantage for you.
Questions & Answers
© 2018 Glenn Stok