Medicare Part C, more commonly known as Medicare Advantage, are private industry HMO and PPO health insurance plans. Those who choose Part C trade their Original Medicare benefits (Parts A and B) for a single managed care policy that covers hospital stays, doctor visits, outpatient care and preventive medicine. The benefit is lower risk of high healthcare bills, and in some cases, additional health care benefits.
Some Medicare Advantage plans offer extra benefits for vision, hearing and dental. Most Part C plans also offer prescription drug coverage.
The benefit of a Medicare Advantage plan is that you get to shop for the options and coverages that best serve you, and the insurance provider takes care of the billing.
Advantage Plan Differences
There are three types of Medicare Advantage plans available: HMO, PPO and PFFS (Private Fee for Service). There’s also a Special Needs Plan that covers those with special health needs as well as specific chronic health related issues. If you opt to select the Special Needs Plan, it must include parts A, B, and D. Here’s a quick overview of the differences between the three types of Medicare Advantage plans:
Medicare Preferred Provider Organization (PPO) – You are able to see any doctor or specialist that you choose. If they are not in your PPO network, your cost will increase. In most cases you can see a specialist without a referral.
Medicare Health Maintenance Organizations (HMO) – You are able to visit doctors in the HMO network only. It is most often necessary to request a referral in order to visit a specialist.
Medicare Private Fee-for-Service (PFFS) – You are able to see any doctor or specialist, but the providers you use must be willing to accept the PFFS’s fees, terms and conditions. It is not necessary to have a referral to see a specialist.
Medicare Special Needs – These plans are designed for people with certain chronic diseases or other special health needs. These plans must include Part A, Part B, and Part D coverage.
Shopping For An Advantage Plan
When you compare plans, be sure to consider deductibles and drug co-pays as well as the plan premium. Rates are not standardized by the government. Although many Advantage plans are full covered by your flat-rate Part A and Part B premium, your out-of-pocket expenses will be different with each plan.
Remember, Medicare Part C combines your Part A and Part B options and optionally provides Part D drug coverage, as well. It’s called Medicare Advantage because, in most cases, it is a lower cost alternative to Original Medicare. Be mindful of the fact that the insurer sets service limits. This is how they control costs.
Medicare Advantage And Your Health Care Providers
All Medicare Advantage plans and the carriers are different. In the case of an HMO plan, most insurance carriers coordinate your health care through a primary care physician. They manage your needs with the specialists and hospitals that deliver the care. In this type of plan, most often you will need to use the doctors and hospitals within the plan’s network.
PPO based Medicare Advantage plans are more flexible. A PPO plan allows you to get your healthcare from any eligible provider. Medicare-eligible providers accept the terms, conditions and payment rates of the plan before providing coverage. Providers can decide whether or not to accept those terms, conditions and payment rates each time they furnish covered services.
How An Advantage Plan Affects Your Original Medicare Benefits
If you choose a Part C plan you will remain in the Medicare Program, however, you give up your normal Part A and B coverage. You continue to have Medicare rights and protection, and you can switch back to Original Medicare later if you decide the Part C plan does not suit your needs.
Be aware that Part C plans are specific to each state and county. You must reside in the prescribed service area of the plan you wish to join. If you have End-Stage Renal Disease, in most cases you will not be permitted to use a Part C plan.
Medicare Advantage is not complicated once you understand the basics. However, before you choose health care insurance, make sure you have a full understanding of both the coverage and premiums.