Medicare Part C is a Medicare health plan offered through a private health insurance company. Medicare was established in 1965 as a government/federal health insurance program.
As of early 2019, there were 22 million Americans enrolled in Medicare Part C, accounting for 34% of all Medicare participants.
In this article, we will cover:
- The Four Parts of Medicare
- Part C (Medicare Advantage) Benefits
- Options for Part C Coverage
- Part C Costs
- How to Apply for Medicare Advantage
What Are The Four Parts Of Medicare?
To enroll in Medicare, you must be 65 and older and/or have a disability or illness that qualifies for Medicare coverage.
There are four parts of Medicare, known as Part A, Part B, Part C, and Part D.
- Part A and Part B are referred to as Original Medicare.
- Medicare Part C, also known as Medicare Advantage, offers many of the same benefits as Original Medicare. Unlike Parts A and B, which are managed by a federal agency, Part C is provided by private health insurers.
Part A and Part B are referred to as Original Medicare. Medicare Part C, also known as Medicare Advantage, offers many of the same benefits as Original Medicare. Unlike Parts A and B, which are managed by a federal agency, Part C is provided by private health insurers.
What Are Extra Benefits Under Medicare Part C?
Medicare Part C covers many of the same benefits as Original Medicare. For instance, the law requires Original Medicare and Medicare Part C to cover emergency care.
With Part C, you’ll receive your inpatient care coverage through Part A and your outpatient/lab services through Part B. Hospice care is not covered by any Medicare Part C plan, but it is included in your Medicare Part A coverage.
Medicare Part C offers additional coverage, but these extra benefits come with a price tag. However, the cost is usually less than what you’d pay for private health insurance outside of the Medicare program.
Depending on the plan, additional coverage can include dental, vision, and transportation services to doctor appointments or adult day care services.
Benefits and services that exceed Original Medicare coverage are optional and determined by the private insurer. You will need to compare different Medicare Part C plans to determine which one is the best fit for you.
What Are The Options Under Medicare Plan C?
Under Medicare Part C, private insurance companies offer three different plans. Known as Advantage plans, these health plans cover different benefits and have unique fee structures.
The three plans are Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Private Fee-For-Service Plans (PFFS).
| HMO | PPO | PFFS | |
| Primary care physician | Yes, in most cases | No | No |
| Out-of-network coverage | Only in emergencies | Yes with a fee | Usually, and with a fee |
| Specialist referral needed? | Yes | Yes, in most cases | No |
| Prescription drug coverage | Yes, in most cases | Yes, in most cases | Sometimes |
Health Maintenance Organization (HMO). Medicare Advantage HMO only covers services within your physical network. This plan also requires that you choose a primary care physician within the network. Once you choose a primary care physician, this plan does not allow you to see another physician. If you need to consult a specialist, he or she must be referred by your physician, otherwise this plan will not cover the service.
Preferred Provider Organization (PPO). Medicare Advantage PPO allows you to see a physician outside of your physical network for an additional fee. With this plan you do not have to select a primary care physician. Also, you can see a specialist without a referral.
Private Fee-For-Service Plans (PFFS) plans. With Medicare Advantage PFFS, you can see any physician that accepts your insurance, and you do not need a specialist referral. This plan offers a great deal of flexibility and freedom when choosing a service provider. However, this flexibility does come with a fee. Also, a service provider may accept your insurance for some benefits, but not others.
How Much Does a Medicare Part C Advantage Plan Cost?
Each Medicare Advantage plan under Part C has a different cost structure. Below are the components that make up this structure.
- Premiums. To enroll in Medicare Part C, you must be enrolled in Parts A and B. Each part has a premium associated with it. This premium is a monthly fee. Under Medicare Part C, you will pay the Medicare Part B premium and the premium associated with Part C.
- Copays. This is a flat fee you pay for each health visit.
- Deductible. This is the amount you’ll pay for covered services out-of-pocket before your insurance plan kicks in and pays any expense.
- Coinsurance. Once you reach your deductible, you will split the cost with your insurance company. This is known as coinsurance. The percentage split varies by plan.
- Out-of-pocket limit. Once you spend a certain dollar amount in a calendar year on your health, the insurance company will assume responsibility and cover 100% of all out-of-pocket costs. This threshold is known as the out-of-pocket limit. The limit varies by plan because each insurer can set their own limit within the federal maximum limits. For in-network providers, the maximum is $6,700, and for out-of-network providers, it is $10,000.
When Can I Apply For Medicare Part C?
The first step is to enroll in Medicare Part A and Part B (Original Medicare). If you’re 65 and have paid into Medicare for the last ten years through payroll taxes, you’re automatically eligible to be enrolled in Original Medicare through your federal retirement benefits.
If you’re 65 and not enrolled in federal retirement benefits, you will need to enroll in Original Medicare. You can visit your local Social Security office, call 1-800-772-1213, or visit SSA.gov and fill out an online form.
Once you’re enrolled, you can shop for your preferred Medicare Advantage Part C. We suggest talking to a professional to learn about the best plan for your personalized needs. Depending on the Medicare Advantage plan you choose, you may need to reside within a specific service area.
Keep in mind that there are designated enrollment periods. If you’re a new Medicare recipient, you have seven months to enroll beginning three months prior to your 65th birthday. This is known as your Initial Enrollment Period.
After your Initial Enrollment Period, you have two other options for enrollment. You can enroll during the Open Enrollment Period between October 15 and December 7 of every year.
Or, you can enroll during special enrollment periods. This occurs after a relocation (such as moving to another state) or with the loss of health coverage.
Many people choose a Medicare Advantage Part C plan because it offers more flexibility and additional coverage. However, it does come with a heftier price tag, a restricted network of physicians, and the complexities associated with private insurers.
