Medicare Part C is the official name for the program known as Medicare Advantage.
Medicare Part C plans are optional, private insurance plans that give you an alternative to traditional Medicare. Not everyone needs Medicare Part C.
How Medicare Part C Plans Work
Picture Medicare Advantage plans as a package deal where you’ll have Part A, Part B, and typically Part D together in one big plan. You’ll get one ID card to use at the hospital, doctor’s office, and pharmacy. Most Medicare Advantage plans have a built-in Part D drug plan, but in some places you can get them without Part D.
If you had group insurance benefits through former employers, Part C plans will mirror those. There is typically a local network of health care providers for you to use. You’ll pay copays for doctor’s visits, lab work, urgent care, surgeries, ambulance rides, hospital stays, and other routine services.
What Medicare Part C Covers
Part C covers all of the same services that you get from Medicare Part A and Part B. You’ll receive hospital and outpatient benefits. However, rather than paying deductibles and 20% of your medical services, you’ll pay the plan’s copays.
Every Medicare Advantage plan includes a summary of benefits that lists various medical services. This synopsis will display what your copay will be for each service. For example, you may pay $50 for a specialist visit, $20 for lab work, $200 for an MRI, etc.
Some items may have a $0 copay, which means you’ll have no copay for the service. You won’t have to pay more than 20% in the network for any service. A 20% coinsurance requirement would be for things like dialysis, medical equipment, chemotherapy and radiation in several plans.
Everything you spend on Medicare Part A and Part B services goes toward your out-of-pocket maximum. If you reach that maximum, your Medicare Advantage plan will pay 100% for the remainder of the year.
Also, a Part D drug plan is often included in Medicare Part C coverage.
Is Medicare Part C Optional?
Yes, Part C is optional, voluntary coverage. You get to decide whether you want to enroll in Original Medicare or you’d rather have a Medicare Advantage (Part C) plan.
What Does Medicare Part C Cost?
Some Medicare Advantage plans have premiums that are $0, but this doesn’t mean Medicare Part C is free. When you enroll, Medicare pays a set monthly amount to the insurance company to provide your care. The carrier will offer you the lowest possible monthly premium to get you to buy their plan.
Other than your monthly premium, your spending may include deductibles and copays up to the plan’s out-of-pocket cap. Since the Part C plan has to renew its contract with Medicare annually, the premiums, copays, and benefits can and do vary from year to year.
Medicare Advantage Out-of-Pocket Maximums
Unlike Original Medicare, each Medicare Part C plan is required to have an out-of-pocket (OOP) cap to protect you. Medicare sets this amount every year, which is currently $7,550. So, the most you’d spend on the plan for Part A and B services is $7,550. The cap varies by plan and doesn’t include Part D spending. For many people, this OOP maximum makes Medicare Advantage a more appealing option than Original Medicare alone.
Am I Eligible for Medicare Part C?
Any Medicare beneficiary can buy a plan if they meet the criteria. Your age doesn’t matter.
- You must be enrolled in both Medicare Part A and Part B.
- You must live in the plan’s service area.
- You must not have End-Stage Renal Disease.
We explain more about the requirements on our Medicare Eligibility page.
You can only enroll into or cancel a Medicare Advantage plan during certain periods. You can enroll during your initial enrollment period or during the annual fall election period (AEP), which goes from October 15 to December 7. Then, your benefits will begin on January 1.
Also, there are special election periods (SEPs) for Medicare Advantage plans, like when you waive employer group coverage or move out of state and drop your plan. If this happens, you’d be given a SEP to enroll in a Part C plan (mid-year) in your new state.
Medicare Advantage plans have special rules, networks, and enrollment periods. Certain restrictions and copays may apply. When you meet with us, we’ll help you understand all the ins and outs before you apply for a Part C plan.
We can also help you choose a plan that will be approved by your doctor and provide you with affordable benefits. Call Cornerstone Senior Advisors at (316) 260-3331