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Medicare Part C

Medicare Part C, also known as Medicare Advantage (MA) plan, is an alternative way to get Original Medicare (Part A and Part B). It is also a cost-effective and potential saving option because it has out-of-pocket limits on costs associated with your covered services. Once you reach the limit, you pay nothing for the rest of the year.


Unlike Original Medicare, Medicare Part C is offered by private insurance companies. Federal government rules and regulations, however, regulate these private companies.

What Does Medicare Part C cover?

Medicare Part C offers the same coverage as Part A (Inpatient/hospital services) and Part B (outpatient/medical services). It also provides supplemental coverage for certain items and services depending on your plan. Additional items and services that Medicare Part C covers include:

  • Prescription drug coverage (Medicare Part D)

  • Vision care, including glasses and contacts

  • Routine dental care, including x-rays, exams, and dentures

  • Hearing care, including testing and hearing aids

  • Wellness programs and gym memberships

  • Adult day-care

  • Medical Transportation

  • Non-medical services including meal delivery, home air cleaners, and home modifications.

What Are The Gaps In Medicare Part C?

A Medicare Part C beneficiary may experience limited access to care depending on the plan they are subscribed to. Moreover, plan availability and benefits vary from country to country.


Additionally, private companies often have networks. These networks include hospitals, primary care physicians, specialists, other healthcare professionals, dialysis centers, laboratories, healthcare stores, and suppliers.

Hence, to enjoy the best from a Medicare Advantage plan, you must find and get care from Medicare doctors and other health professionals within your plan’s network.

What Are The Various Types of Medicare Part C Plans?

Medicare Part C plans are of 5 different types. They are:

  • Health Maintenance Organization (HMO) plans

  • Preferred Provider Organization (PPO) plans

  • Private Fee-for-Service (PFFS) plans

  • Special Needs Plans (SNPs)

  • Medicare savings account (MSA) plans

Health Maintenance Organizations (HMOs) Plans

With HMO plans, you enjoy Medicare benefits only when you get your care and services from providers within the plan’s network.  


Some HMOs, however, offer a point of service (POS) option which allows you to get certain out-of-network services. These out-of-network services often cost more than if you had gotten them from a network provider. 


Most HMO plans cover prescription drugs and hence, are recommended if you will benefit from having a drug plan. Note that you cannot subscribe to a separate Medicare Part D plan.


With an HMO plan, there are certain services you may get from any other provider, even if they do not participate in your network. They are:

  • Emergency care

  • Out-of-area urgent care

  • Out-of-area dialysis

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Preferred Provider Organizations (PPOs) Plans

With a PPO plan, you can use any doctor, healthcare provider, or hospital of your choice, as long as they accept Medicare. You pay less if the healthcare provider or facility is within your plan's network and more if they are not. 


PPO plans often cover emergency and urgent care. Most PPO plans also offer prescription drug coverage. You cannot join a separate Medicare Part D (drug coverage) plan if you have a PPO plan. Hence, if you will benefit from drug coverage, join a PPO plan that offers drug coverage.

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Private For-for-Service (PFFS) Plans

PFFS plans draw their payment terms for healthcare providers, facilities, and clients when they get care. You can see any health-care provider within the plan's network or any out-of-network Medicare provider who accepts to treat you on the plan’s payment terms. Usually, services from providers outside the plan’s network cost higher and, in some cases, may not be covered by your plan.


Some PFFS plans offer drug coverage and are recommended for clients that will benefit from drug coverage.

Special Needs Plans (SNP) Plans

Special Needs Plans can be like HMOs or PPOs. Special Needs Plans are made available to individuals who fit into their policy. The people usually meet specific health criteria, such as having certain chronic and disabling health conditions or qualifying for Medicare and Medicaid. These criteria form the two most common types of SNPs. They are Chronic and Dual Eligible Special Needs Plans (D-SNPs).

Condition Special Needs Plans (C-SNPs)

This plan is for those with chronic health conditions. At the time of enrollment, your physician will be asked to fill out a chronic condition verification form. 


This type of SNP usually has a network including hospitals, pharmacies, physicians, specialists, and other health professionals who specialize in treating chronic diseases or conditions that affect their members. Examples of such chronic diseases include heart disease and diabetes.

Dual Eligible Special Needs Plans (D-SNPs)

People eligible for both Medicare and Medicaid are known as the dual-eligible population. D-SNPs are available to this group of people and are characterized by very low costs in terms of premiums, deductibles, copays, and other out-of-pocket costs.


Some D-SNPS, like other managed care plans, may provide supplemental coverage for dental care, vision care, meal delivery, and transportation to and from physician offices. 


To enjoy the highest coverage and benefits from SNPs, you must receive non-emergency care from in-network providers. Some SNPs cover services from providers out of network, while some do not and may affect your costs. All SNPs must provide drug coverage.

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Medical Savings Account (MSAs) Plans

MSA plans are not so common. Clients with MSA plans have a high deductible and health savings accounts where they deposit money monthly. MSA plans do not have drug prescription coverage.

Am I eligible for Medicare Part C?

Eligibility is the same as Original Medicare. You must be aged 65 and meet the following criteria to qualify for Medicare Part C:

  • Must be a U.S. citizen or a permanent legal resident who has lived in the United States for at least five years

  • Must be receiving (or eligible to receive) benefits from Social Security or Railroad Retirement Board 

  • You or your spouse must be a government employee or retiree who has not paid into Social Security and has paid Medicare taxes while working for at least ten years (40 quarters). This means you have earned 40 Social Security Credits.


If you are under-65, you are eligible for Medicare Part C if you:

  • Have end-stage renal disease (ESRD)

  • Have amyotrophic lateral sclerosis (ALS)

  • Have qualified for Social Security retirement benefits and have received Social Security Disability Insurance (SSDI) for at least 24 months (not necessarily consecutive)

  • Have qualified for certain disability benefits from the Railroad Retirement Board for 24 months

  • Have family relationship coverage, when a person's parent or a spouse paid Medicare taxes for a specified period

How Do I Enroll In Medicare Part C?

You can enroll in a Medicare Part C plan during one of these periods.

Initial Enrollment Period

If you are applying for Medicare for the first time, you can choose a Medicare Advantage plan during the Initial Enrollment Period (IEP). 


The initial enrollment period refers to the 7-month window you have to enroll in Medicare when you turn 65. This 7-month period includes the three months before the month you turn 65, your birth month, and three months after the month you turn 65.

Medicare Open Enrollment Period

The Medicare Open Enrollment Period is also known as the Annual Enrollment Period (AEP) and runs from October 15 through December 7 every year.


If you’re already enrolled in Original Medicare, you can change to a Medicare Part C plan during the Medicare Open Enrollment Period. During this time, you can also switch to another Medicare Part C plan if you were already enrolled in one Medicare Part C. All changes you make during this period will go into effect on January 1.

Medicare Advantage Open Enrollment Period

This runs from January 1 to March 31 each year. During this period, you can switch from one Medicare Advantage Plan to another, purchase a Medicare Part D plan (for MSA plans that do not provide it), or remove it.

Special Enrollment Period

This enrollment period only happens when there is a qualifying situation or event for it. This may be relocation, marriage, childbirth, or losing other health coverage. In this period, you can enroll in a private health plan or change your Medicare enrollment to another private plan.

What Are Medicare Part C (Medicare Advantage Plan) Costs?


The premium you'll pay when enrolled in a Medicare Advantage Plan depends on the plan. Some plans do not charge a monthly premium, while some do. If your plan does, you will pay the stated amount in addition to the Part B premium and the Part A premium (if you are not enrolled in premium-free Part A).

Deductibles, Coinsurance & Copayments

The amount you pay for Part C deductibles, coinsurance, and copayments varies by plan. 


They also depend on:

  • The healthcare services you need and how frequently you need them

  • Whether you need extra benefits and if your plan charges for it

  • Whether or not you go out-of-network

  • The plan you're on (HMO, PPO, PFFS, SNP, or MSA)

  • Whether your plan has a yearly limit on your out-of-pocket costs for all medical services

  • Whether you have Medicaid or get help from your state

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