What You Need to Know About Medicare Advantage Part C Plans
Medicare Advantage (MA) Part C plans are privately owned Medicare plans offered by health insurance companies. These plans are regulated by the Centers for Medicare and Medicaid Services (CMS) and must offer all of the same benefits as Medicare Part A and Part B, but they can also include additional benefits for enhanced coverage.
For example, many Part C plans also offer dental, hearing, and prescription drug coverage, adult day care services, and transportation, among other benefits.
Here’s what you need to know about how MA plans work.
What is Medicare Advantage (MA) Part C and What Does it Cover?
All U.S. citizens are eligible for Original Medicare (Part A and Part B) when they turn 65. Some people are also eligible at a younger age if they have certain qualifying conditions.
In broad terms, Part A covers hospital services and Part B covers physician services. In addition, to offset the high cost of prescription drugs, many people also choose to enroll in Medicare Part D which covers prescription drug costs.
With this amount of coverage, many people wonder if they need Part C coverage as well.
If you decide that you want enhanced benefits at prices that are lower than regular private insurance, then an MA plan may be right for you.
Keep in mind that you’ll need to keep Part A and Part B coverage, and you will need to pay an additional premium for Part C coverage. Also, you’ll need to live in a particular MA plan’s coverage area to buy it.
You need to be aware of out-of-pocket costs, too.
If you have Medicare Part C, the maximum out-of-pocket limit is $6,700 per year for services that Medicare Parts A and B cover if you go to in-network care providers. The limit is $10,000 per year for combined in-network and out-of-network costs. Actual limits may be different because insurers set their own limits, as long as they don’t exceed these maximum amounts.
Due in part to laws passed in 2018, Part C plans have some flexibility when it comes to benefits. They can cover “daily maintenance” items like wheelchair ramps and home modifications as well as durable medical equipment, home health services, and telehealth.
They can also cover transportation services to help you get to your doctor’s office or pharmacy.
Home Health Nurses and Telehealth
Beginning in 2018, MA plans began to offer coverage for doctor house calls, home nurses or aides to help with dressing and daily activities, over-the-counter pharmacy products, and non-emergency transportation (defined as the ability to schedule a ride to your doctor appointments or in some cases, the pharmacy).
Transportation services are usually offered through third-party companies (sometimes including Uber and Lyft) that your health plan is contracted with, so be sure to contact a company that your plan covers to make sure you’re covered.
MA plans now offer “non-skilled” home care for services that do not require a licensed doctor or nurse practitioner. Those services can include things like home cleanup and meal delivery.
Telehealth services are another new benefit that MA plans can offer. Using telehealth, people who cannot leave their home either for medical reasons or for lack of transportation to easily access healthcare online.
If your plan allows telehealth, there will be a list of telehealth providers you can use that will allow you to speak to doctors over the phone or via video chat.
One of the big advantages to telehealth is that doctors are often able to prescribe medications without you having to travel to their offices. In many cases, you can then have those prescriptions delivered through CVS Pharmacy or any other mail-order pharmacy.
Durable Medical Equipment and Home Modifications
Original Medicare only covers medical equipment that is considered “durable” which is generally defined as something that must be usable at home for at least three years.
Some examples of durable medical equipment include oxygen equipment, nebulizers, infusion pumps, wheelchairs, and others. However, Original Medicare does not include home modifications.
MA plans can cover this providing coverage for modifications such as wheelchair ramps, bathroom support bars, stair lifts, automatic doors, and other similar items.
MA plans also often provide fitness benefits, usually as a membership to a third-party program. The two most popular are SilverSneakers and Silver & Fit.
If one of these programs is included in your MA coverage, you will have access to a gym membership and special group fitness classes designed for seniors and Medicare eligible beneficiaries.
Silver & Fit even offers “home fitness kits” for those who need to or prefer to stay at home.
Dental, Vision, and Hearing
In most cases, Original Medicare does not cover dental, vision, and hearing services. The exception for these is if they are related to hospital stays for another reason, in which case, Part A may pick up the costs.
Although exact benefits will vary by plan, MA plans can offer a variety of dental benefits such as
dental exams and cleanings, x-rays, fillings, extractions, root canals, crowns, and even dentures in some cases. There are usually copayments associated with these services.
MA vision benefits can cover exams, glasses, and sometimes contact lenses.
MA hearing benefits generally include exams and hearing aids.
Medicare Advantage Prescription Drug Plans (MAPD)
When shopping for a MA plan, you can purchase a MA only plan or a plan that also includes prescription drug coverage. These are known as Medicare Advantage Prescription Drug Plans or MAPDs.
You also have the option of purchasing a separate Medicare Part D Prescription Drug plan if you prefer.
However, enrolling in a MAPD plan means that you do not have to enroll in Part D or another form of prescription drug coverage. Instead, all of your coverage will be bundled into one convenient plan.
Like any other prescription drug plan, your MAPD coverage will come with a drug formulary, which is a list of prescription drugs your plan covers. Most formularies are split into tiers that indicate what your co-payment will be for each prescription.
In many cases you may have co-payments for your prescriptions with a MAPD option, but there are $0 premium plans available in some areas.
Do Most Doctors Accept Medicare Advantage Plans?
People with Original Medicare have access to doctors throughout the United States. It’s estimated that about 93% of all primary care providers accept Medicare.
However, with MA plans, things work a bit differently. Not every doctor who accepts Original Medicare will accept patients with an MA plan, and vice versa.
You may be covered out-of-network for emergency room and urgent care at in-network rates, but things can quickly get complicated on the billing side of things.
Per CMS, all MA plans must include an adequate number of providers and hospitals in their networks. If you have to seek routine care from an out-of-network provider, your insurer may cover services at in-network rates if an appropriate provider is not available in-network.
Enrollment by is Determined by Your Location
Plans you can enroll in vary based on where you are located. Most MA plans are only available in certain states and counties.
Each plan will be customized to its location and will have its own provider network. Your doctors and pharmacists will most likely not accept every plan, so a good place to start would be figuring out which plans your favorite doctors and pharmacies accept.
Service Areas are determined by ZIP Code, region, county, or partial-county (in densely populated areas like Los Angeles, for example).
If you move from one state to another or out of an MA Service Area, and you don’t have access to the same coverage, you will qualify for a Special Enrollment Period so that you can get new coverage.
When you are ready to move, you can ask a Medicare representative for assistance finding a new Medicare plan in the Service Area where you plan to live.
The Different Types of Medicare Advantage Plans
There are six major types of MA plans and all are commonly referred to as Coordinated Care plans (except for Medical Savings Accounts). Coordinated Care plans offer health care through an established provider network approved by the CMS.
Health Maintenance Organization (HMO) – You select one primary physician. In some cases, you may only receive coverage for that one doctor (unless he or she refers you to a specialist).
Point-Of-Service (HMO-POS) – You’ll select one primary physician, but you’ll have the freedom to visit any specialist in your network for your other needs. You will be charged a fee for visiting specialists.
Preferred Provider Organizations (PPO) – You can see any doctor, but your costs will be lower if you choose one that is in your network.
Private Fee-For-Service (PFFS) – You will not need referrals or a primary physician, but you’ll have to pick a doctor that accepts your PFFS plan.
Special Needs Plans (SNP) – Designed for those who are eligible for both Medicare and Medicaid, live in a nursing home, or have a chronic illness or disability.
Medical Savings Account (MSA) – Works like a tax-free savings account for your medical bills. Medicare will deposit money into your HSA. You can use that account to pay for medical expenses.
Contact Medicare Plan Finder to get in touch with a benefits advisor who can help you select the best type of Part C plan for you and your needs or call now at 833-328-3676.
How Medicare Supplement Insurance (Medigap) Policies Work with MA Plans
Medigap policies help fill in the gap in Original Medicare. These policies are sold by private companies and will help bridge expenses for deductibles, copayments and coinsurance costs.
However, as of January 1, 2020, Medigap plans sold to new people with Medicare aren’t allowed to cover the Part B deductible. Due to this change, Medigap Plans C and F are no longer available to new Medicare beneficiaries starting on this date. If you already have coverage under Plans C and F, you can keep your plan.
A Medigap policy is different from an MA plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your benefits from Original Medicare.
You can’t own both a Medigap and a MA plan at the same time. So you need to decide which one provides benefits more suited to your needs and buy accordingly if you’re looking for enhanced coverage.
Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, get a MA plan that includes prescription drug coverage or a separate Part D plan.
Also consider that Medigap policies generally don’t cover vision or dental care, long-term care, hearing aids, eyeglasses, or private-duty nursing.
Policy choices and coverages can be confusing, so it’s best to have an idea of what kind of coverage you want and then work with a licensed agent to help you find the best plan for your situation.
Is Medicare Advantage Based on Income?
No. But for Medicare Part B, your premiums may be based on your modified adjusted gross income (MAGI), defined as your total adjusted gross income plus tax-exempt interest, taken from the most recent tax data Social Security has from the IRS.
The higher income threshold for 2018 was $87,000 for an individual taxpayer and $174,000 for a married couple filing jointly. Up to those amounts, your Part B premium for 2020 would be $144.60 per month.
At higher incomes, premiums rise to a maximum of $491.60 a month if your MAGI exceeds $500,000 for an individual, $750,000 for a couple.
Keep in mind, private insurers offer MA plans, and they are free to set costs in relation to what the market will tolerate.
The only other government health insurance program based strictly on income is Medicaid.
Can Medicare Advantage Plans be Free?
Some MA plans are labeled as free because they offer $0 premiums to be enrolled in the plan. This can be an attractive alternative for those people looking to save money.
There’s generally no difference in coverage between a free plan and a paid plan because regardless of cost, most MA plans offer parts A and B, prescription drugs, and other additional coverage.
Some companies are able to offer $0 premium plans because when they contract with Medicare, they are given a set amount of money to cover Part A and Part B insurance. If a company can save enough money elsewhere then it may be able to pass along savings to members, up to and including $0 premium plans.
Here’s the catch.
While you may pay no premiums in some cases, you will still probably have to pay deductibles, copayments and coinsurance. Also different plans will offer different costs based on their structures. For example, PPO plans charge different copayment amounts based on whether your provider is in-network or out-of-network.
And don’t forget, even if you get a $0 premium MA policy, you’re still responsible for paying your Part B premium every month.
You can find Medicare Part C plans with a $0 premium in your area by talking with a Medicare Plan Finder agent or by using Medicare’s Find a 2020 Medicare plan tool.
When You Can Enroll in a Medicare Advantage Plan
Most people are eligible to enroll in Original Medicare during their Initial Enrollment Period (IEP). The IEP is a 7-month window that lasts from three months before your 65th birthday, includes your birthday month and ends three months after. During that time, you can also enroll in an MA plan.
If you don’t enroll in MA during your IEP, you can select a MA plan during Medicare’s Annual Enrollment Period (AEP). It takes place every October 15 through December 7.
Some special circumstances may also allow you to enroll during other times of the year.
Late Enrollment Penalty
If you don’t enroll in a Medicare plan during your IEP, you may have to pay a late enrollment penalty fee. The penalty is designed to encourage you to enroll as early as you are eligible.
Even though you can enroll in a MA plan or change into a new MA plan during the AEP every year, you’ll save money if you enroll when you’re first eligible.
Special Enrollment Periods
Some people may be eligible for a special enrollment period. That means that during each of the first three quarters of the year, you have one opportunity to switch plans if you discover a plan that is better for your needs.
Often, people who are eligible for a Medicare Savings Program, a State Pharmaceutical Assistance Program, a Special Needs Plan, or Social Security benefits, are eligible for a special enrollment period.
People who qualify for both Medicare and Medicaid are also often eligible. There may be some limitations (for example, those at risk for opioid addiction may not be able to switch plans).
Additionally, some circumstances allow Medicare beneficiaries a temporary special enrollment period. If you move to a new service area, lose or start a job, move into or out of a healthcare facility, end incarceration, or lose Medicaid eligibility, you will be granted a 60-day period to find a new plan that better fits your needs.
Medicare Advantage Open Enrollment Period
If you decide that you are not happy with your MA plan, you have a few options.
You can switch to a different type of plan during the Annual Enrollment Period, or you may be eligible for the Open Enrollment Period (OEP).
If you realize that the plan you chose does not actually cover everything you want, or your doctor is not in your network, you can make one change from January 1 through March 31.
During the OEP, there are only a few types of changes you can make. You can switch from one MA plan to another MA plan, or you can switch from a MA or MAPD plan back to Original Medicare with the option to add Part D.
Who Qualifies for Medicare Advantage Plans?
You’re eligible for an MA plan as long as you live in the plan’s service area and you have Original Medicare (Part A and Part B).
The only exception is for those who have End-Stage Renal Disease (ESRD). Only a few MA plans cover people who have ESRD, and they are available only in a few specific service areas.
A Medicare Plan Finder agent in your area can help you find out if there is an ESRD-friendly Medicare Advantage plan available to you.
Medicare Advantage Pros and Cons
What are the advantages and disadvantages of Medicare Advantage plans? Here are a few things to consider as you weigh your Medicare coverage and benefit options:
MA plans often offer more benefits than you get with Original Medicare. MA plans most offer at least the same level of coverage, but it’s common to also include extras like dental, vision, fitness and wellness services and prescription drug coverage.
You may pay less overall because you may be able to sign up for a $0 premium plan and your cost sharing will be less with an MA plan than with simply Original Medicare coverage in place.
MA plans limit your maximum out-of-pocket expense. Unlike Original Medicare, once you have spent that maximum, you pay nothing for covered medical services for the rest of the year.
Medicare Advantage plans are managed care and coordinate services among your health care providers. For example, an HMO plan will require you to select a primary care physician who will then coordinate your overall care.
You can get the added convenience of working with one plan administrator for all your healthcare needs, including vision, dental, prescription drugs and other added benefits.
Your healthcare choices may be limited due to restrictions in provider networks. If you go out of network, you could be stuck paying heavy out-of-pocket costs.
Some MA coverage requires a doctor’s referral and plan authorizations. MA plans do this to prevent the misuse or overuse of healthcare resources. You might need prior authorization for hospital stays, home health care, medical equipment, and certain complicated procedures.
MA plans have geographic limitations for service areas. Most plans are regional networks of providers. To enroll, you must live in the provider’s service area for at least six months out of the year in most cases.
The Best Medicare Advantage plans for 2020
There really is no simple answer for which Medicare Advantage plans are the best for 2020. That’s because every person needs different things out of their plan, so what works best for one person won’t work best for the next person.
Like any other major purchase, you’ll need to do some shopping and compare plan features, coverages, costs and more before deciding.
Also remember that not all plans are available in all geographic areas, so finding the perfect plan means nothing if you can’t access it because of where you live.
Not all plans offer the same benefits, so you need to consider how your needs have changed, and what kind of benefits you must have (vision, hearing, prescription drugs, etc.) to meet your unique needs.
Review your current coverage, if applicable, and talk to experts who can determine if new plans are on the market and how these plans best work with all of your other possible coverages for the coming year.
How Do I Get a Medicare Advantage Plan?
There are several resources you can access for more information and to enroll in a Medicare Advantage plan.
The Medicare Plan Finder tool helps you view and compare all available drug and MA plan choices. You can search by ZIP code online. You can also log in to your MyMedicare.gov account for personalized results.
Call the Medicare Call Center at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048 to get help with specific questions about billing, claims, medical records, expenses, and more.
Contact the State Health Insurance Assistance Program (SHIP) in your state.
SHIPs provide local health insurance counseling to people with Medicare at no cost to you. SHIPs aren’t connected to any insurance company or health plan. SHIP volunteers can help you with these Medicare questions or concerns about billing, your Medicare rights, complaints, and finding help paying for healthcare costs.
You can also contact Medicare Advantage plans directly for detailed information about coverage and costs.
Find Medicare Advantage Plans Available in Your Area
Your best bet is to give us a call. We’re a great resource for helping you find the right Medicare Advantage Plan.
We have MA agents in 38 states who can sell plans from most major carriers. Contact Medicare Plan Finder to discuss your Medicare options.
There is never any obligation to buy, and all of the information is free. You can also give us a call at 833-438-3676.