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Understanding Medicare Part C

When determining how to obtain your Medicare benefits, you have two primary choices. One is to opt for Original Medicare. This consists of going with Medicare Part A for your hospitalization coverage and Part B for your doctors’ and medical services. With this plan, you may also choose to purchase Medicare Part D in order to help in covering the cost of your prescription medications.

The other option that you have is to go with a Medicare Advantage plan. This alternative, also known as Medicare Part C, provides you with another way of essentially receiving your Medicare Part A and Part B coverage, but with additional coverage as well, such as dental, vision, or wellness benefits. There are also medicare supplements that you can enroll in that will help cover the costs that Medicare does not cover, such as Medigap Part F and Medigap Part G.

Medicare Part C board

What Do Medicare Advantage Plans Cover?

Medicare Advantage plans can cover a wide variety of health care services. These plans are required to provide all of the same items that Medicare Part A and Part B cover, other than hospice care. This is because Original Medicare will cover hospice care – even if you are enrolled in Medicare Advantage. Also, for all types of Medicare Advantage plans, you will be covered for emergency care services, too.

However, a Medicare Advantage plan may opt not to provide coverage for services that are not considered to be medically necessary under Medicare. Therefore, if you are unsure of whether or not a service will be covered, you may want to check with your provider before moving forward with a particular procedure or service.

In addition to the same services that are offered under Medicare Parts A and B (Original Medicare), Medicare Advantage plans may also provide additional coverage as well, such as vision, dental, and or wellness benefits. Also, most Medicare Advantage plans will include Medicare Part D prescription drug coverage.

Types of Medicare Advantage Plans

Unlike Medicare Part A and Part B where there is just one plan of coverage to choose from, there are many different types of Medicare Advantage plans available. These include the following:

  • HMO (Health Maintenance Organization) – Medicare Advantage HMOs work like a Health Maintenance Organization in that enrollees will receive their health care services from medical professionals who are in a particular network. An individual may not be covered if he or she goes outside of the network to receive their care unless they first receive a referral from their primary care provider.
  • PPO (Preferred Provider Organization) – In a plan that works in a PPO format, there will also be a network of providers. However, an enrollee may still be covered for services if he or she obtains services from a health care provider that is outside of the network – the cost may just be higher regarding the copayment or the coinsurance.
  • PFFS (Private Fee for Service) – A Medicare Advantage Private Fee for Service plan will allow its enrollees to see any health care provider that is approved by, and that accepts, Medicare as well as the insurance plan’s payment. Therefore, it is essentially the insurance plan – rather than Medicare – that decides how much will be paid, as well as which of the services the enrollee may receive.
  • SNP (Special Needs Plan) – A special needs plan will limit its membership to only those enrollees who fit into certain specific criteria. For example, only individuals who possess certain types of chronic health issues and /, or those who are considered to be dual eligible (those eligible for both Medicare and Medicaid coverage) can be enrolled. Also, a special needs plan may also often require that its enrollees obtain services from health care providers who are within a certain network.
  • MSA (Medical Savings Accounts) – These plans are similar to the Medical Savings Plans that are also available outside of Medicare. Here, enrollees have some flexibility in choosing both their providers, as well as their overall health care services. There are two key parts to an MSA plan. These plans combine a high deductible health insurance plan, along with a medical savings account from which the enrollee may be able to withdraw funds with which to pay for his or her health care costs prior to meeting the health insurance policy deductible.

How Much Does Medicare Advantage Coverage Cost?

In addition to your Medicare Part B premium, you will typically also be required to pay a monthly premium amount for Medicare Advantage if you choose to go with this coverage. The amount of the Medicare Advantage premium will differ, depending on the benefits that are offered, the insurer that it is purchased through, and the area in which you live.

In 2016, the Medicare Part B premium that most people pay is $104.90 per month – provided that you have this premium deducted from your Social Security benefit. However, if you have not yet enrolled in Social Security, or if you will just be enrolling in Medicare in the year 2016, then your monthly premium amount will be $121.80.

If, however, you earn what is considered to be a high income (according to Medicare), and then you may be required to pay a higher amount of part B premium. This is determined based upon your modified adjusted gross income from two years prior. So, for example, your 2016 Medicare Part B premium amount would be based upon your 2014 modified adjusted gross income – as well as the way in which you file your tax return – as follows:

Medicare Part B Costs

Individual Tax ReturnJoint Tax ReturnMarried and File a Separate Tax ReturnYour Part B Premium
$85,000 or less$170,000 or less$85,000 or less$121.80
Above $85,000 up to $107,000Above $170,000 up to $214,000 N/A $170.50
Above $107,000 up to $160,000Above $214,000 up to $320,000 N/A $243.60
Above $160,000 up to $214,000Above $320,000 up to $428,000 N/A $316.70
Above $214,000 Above $428,000 N/A $389.80

In addition to the premium, there may be other costs involved with a Medicare Advantage plan, too. These can vary a great deal, depending upon whether or not the plan has an annual deductible, or any other type of deductible(s) associated with the coverage that you obtain.

The plan may also charge you a copayment or coinsurance amount each time you see a doctor. The amount of this coinsurance and / or copayment may be different than that which is charged under Original Medicare (Medicare Parts A and B).

Costs can also vary depending on the type of health care that you require, as well as how often you require such care. Likewise, costs can also be affected if you meet or exceed the plan’s annual limit for any of your medical services.

In addition, if you have a Medicare Advantage plan that operates as an HMO or a PPO, your expenses can be affected if you do or do not see health care providers that are within a particular network.

It is important to note that unlike with Original Medicare, where you are able to purchase a Medicare Supplement insurance policy to help in alleviating the cost of your out-of-pocket expenses, those who own a Medicare Advantage plan are not allowed to purchase a Medicare Supplement plan.

Where to Find the Best Premium Quotes on Medicare Advantage Plans

If you are seeking the best premium quotes on Medicare Advantage plans, the best course of action is to work with a company or an agency that has access to more than just one insurance carrier.

Unlike Medicare Part A and Part B coverage, Medicare Advantage plans are not offered directly through Medicare. Rather, these plans are provided by individual insurance companies that have been approved by Medicare. Therefore, the plan offerings, as well as the premium prices, can vary, based on what is being offered, as well as by where you reside geographically.

If you find that you still have any questions at all regarding Medicare Advantage coverage – or even if you have a question about Medicare in general – please feel free to contact us. We can be reached directly by phone, toll-free, by dialing 800-376-0824.

Our experts will be happy to walk you through any of the information that will help you in better understanding your Medicare Part C benefit plan choices. Today, there are many plans that Medicare enrollees have available to them – and we are here to ensure that you get the best Medicare Advantage benefits for your specific goals and needs. So, contact us today – we’re here to help.


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