I. What Medicare Part C Covers

Medicare Part C can cover many different things, from hospital stays to new eyeglasses. It’s bundled the coverage that Medicare Part A and Part B offer into one plan. However, under Medicare Part C, you’re typically required to use in-network hospitals and healthcare providers, including rehabilitation and specialist services.

Inpatient Hospital Care

Traditional Medicare Part A covers hospital stays, including broken bones, illnesses, or a stroke. The typical coverage includes the first 60 days that you’re in the hospital, although some services may be extra. Depending on the plan you choose for Medicare Part C, however, you may opt for higher premiums to ensure that you will have a private room, for example, should you need to be hospitalized.

Skilled Nursing Home Care

If you need mobility assistance, skilled nursing, or physical therapy to recover from surgery or heal from an illness, broken bone, or other condition, Medicare will pay for your stay in a nursing home facility, as part of the Medicare Part A coverage. Nursing homes are different from other types of senior living and hospital care. These facilities typically have medical professionals on hand for rehabilitation therapy, and to help patients heal in a non-hospital setting. There are also care workers on hand to help patients move about, use the bathroom, and remain compliant with their medical directives.

Home Health Care

Home health care often isn’t covered under traditional Medicare but can be covered under many Medicare Part C plans. Home health care involves visits by a healthcare professional for those that are homebound and unable to access medical care in a doctor’s office. You may need a physician’s certification that you need a certain level of care and that you are, in fact, homebound in order to be eligible for these services.

Visiting healthcare professionals can help with many different things, including diabetes management, physical or occupational therapy, dressing wounds, or hospice care. Patients will receive treatment according to their needs, although a doctor will have to re-certify the need for healthcare every 60 days.

Outpatient Medical Care

Outpatient medical care is included with Medicare Part B coverage. This includes regular and specialist physician visits, although you’ll typically need a referral for a specialist if you’re covered under Medicare Part C. Outpatient care includes both medically necessary services and services intended to prevent disease. Coverage includes:

  • Regular and specialist doctor visits
  • X-rays and lab tests
  • Emergency ambulance services
  • Mental health services, both inpatient and outpatient
  • Preventative medication such as vaccines and flu shots
  • Durable medical equipment like wheelchairs, walkers, or C-PAP machines
  • Occupational therapy
  • Physical therapy
  • Speech pathology therapy

The patient’s financial responsibility for these services may be different than that of Medicare Part B patients. Additionally, you’ll have to choose a doctor that’s part of your coverage network.

Dental Care

Medicare Part C covers dental care, whereas, unless it’s an emergency, screening for an operation, or mouth disease, traditional Medicare does not. Medicare Part C dental plans include routine exams and cleanings as well as treatment for gum disease and fillings. Most plans don’t cover cosmetic dental procedures such as braces or veneers.

Vision Care

If you have poor vision, enrolling in a Medicare Advantage plan that covers eye exams and the cost of glasses or contacts may be an option for you.

Hearing Care

Coverage typically includes routine hearing exams and the cost of hearing aids.

Fitness

Some Medicare Advantage plans also cover fitness classes or gym memberships as part of disease prevention.

II. Eligibility for Medicare Part C

Traditional Medicare Eligibility

To enroll in a Medicare Advantage program, you must first be covered by Medicare Part A and Part B. You must be a U.S. citizen or permanent legal resident for at least five years to be eligible for Traditional Medicare. In addition to this, applicants must meet at least one other criteria:

  • Aged 65 and older and eligible for Social Security. Most people are automatically enrolled in Medicare Part A when they turn 65, although they may have to apply for Part B separately. Once you’ve been accepted to both programs, you have the option to seek Medicare Part C plans. In addition, those that receive benefits from the Railroad Retirement Board (RRB) will begin receiving Medicare Part A and B automatically when they turn 65.
  • Be permanently disabled and have received disability benefits for at least two consecutive years. Those who have disability benefits automatically begin receiving Social Security after 24 months.
  • Have end-stage renal disease (ESRD), which is permanent kidney failure that requires dialysis treatment and/or a kidney transplant. These patients will need to sign up for Medicare, as they are not automatically enrolled.
  • Have Lou Gehrig’s Disease

Your financial responsibility for your Medicare Part B premium may vary according to your income level, as well as whether you sign up for Part B once you’re eligible. If you delay signing up, you may be assessed a fee. The standard premium for Part B is $144.60 as of 2020.

Medicare Part C Eligibility

Medicare Part C is private insurance and offers alternative benefits to Traditional Medicare. In order to be eligible for Medicare Advantage plans, you have to live in the area that the plan covers and already be enrolled in Medicare Parts A and B. You’ll have to research the plans on your own and manually apply, although a licensed insurance agent or broker may be able to help you. You may also call 1-800-MEDICARE or go online for more information at www.medicare.gov.

Bear in mind that if you choose Medicare Part C coverage, you’re still responsible for paying for your Medicare Part B premium, as well as the Part C premiums.

III. Enrolling in Medicare Part C

Enrollment in Medicare Part C isn’t automatic, as it’s an optional program. Therefore, clients will need to enroll in Part C themselves. Medicare Part C plans differ by region, so it’s important that you review what each plan covers to make sure that you’re getting the benefits you need. You may do this in one of several ways:

  • The Medicare Plan Finder lists each plan and its benefits
  • Check the website of the plan you want to see if you can enroll online
  • Fill out a paper form, which you can obtain directly from the plan’s insurance carrier, and mail the form back
  • Case managers at Medicare can help with questions. Simply call 1-800-MEDICARE (1-800-633-4227)

IV. Medicare Part C: Initial Enrollment

The Initial Enrollment Period (IEP) for Medicare Part C is the same period as the Traditional Medicare IEP, the three months before the month you turn 65, the month of your birthday, and the three months afterward. However, if you’ve deferred your Part B enrollment, then your Part C IEP won’t begin until you’ve already enrolled in Part B. In these cases, you may be able to sign up for Medicare Advantage during either a Special Enrollment Period or the Part C General Enrollment Period.

V. Medicare Part C: General Enrollment

The General Enrollment Period for Medicare Part C is referred to as the Open Enrollment Period (OEP) or the Annual Election Period (AEP). This is where beneficiaries can either enroll in Medicare or change their existing plans. Many times, people take advantage of this period for Medicare Advantage changes because their preferred physician may have moved to a different PPO or HMO coverage plan, or their needs may have changed, such as needing a vision or hearing care.

The AEP period is scheduled annually from October 15 to December 7. During this time, you may also add Part D coverage if you don’t have prescription drug coverage under your current plan, or change back to Traditional Medicare coverage.

The OEP occurs from January 1 to March 31 each year, with the same ability to end your Medicare Advantage Plan, change to traditional Medicare, change to a different Part C plan, or begin or end a Medicare Part D drug plan.

VI. Medicare Part C: Special Enrollment

Medicare Part C is only offered to those who live within the plan’s coverage area. Therefore, if you move out of your plan’s coverage area, or into an area with different coverage plans, you’ll be able to change your Part C coverage.

VII. FAQs About Medicare Advantage

Many people have questions about Medicare Part C. Here are some of the more common ones:

Will I lose my traditional Medicare coverage when I enroll in a Medicare Advantage Plan?

No. Once you’ve enrolled in Medicare Part A and B, you retain that coverage. However, the private insurance carrier that provides your Part C coverage will take over the administrative role of some of your benefits. You will not lose your Original Medicare, and if you choose to end your Part C coverage, you can easily revert back to traditional coverage during the Annual Enrollment Period October 15 through December 7.

Does Medicare Advantage replace Traditional Medicare?

No. Medicare Advantage is a different type of medical insurance than traditional Medicare. It’s not a replacement for this benefit, and it’s not a supplement. Part C plans are different in that a hospital, specialist, or doctor has to agree to the plan’s terms and conditions before they can treat the patient. The only exception is emergency care.

What types of Medicare Advantage plans are available?

Medicare Advantage plans include a few primary care types, and most of these plans include prescription drug coverage.

  • Health Maintenance Organization (HMO): This program contracts through Medicare to give beneficiaries access to a network of doctors and hospitals that coordinate care, with the focus on illness and disease prevention. Enrollees will have access to more benefits than those who have Traditional Medicare and many of the Medicare Supplement plans. However, if you are covered by an HMO, you must have treatment within your network of doctors and hospitals; otherwise, you may be responsible for paying for all the treatment.
  • Health Maintenance Organization with Point of Service Option (HMO POS): This network is more flexible and allows beneficiaries to seek care outside of their traditional HMO network. This applies to certain situations and certain treatments, although you may pay some additional fees if you choose an out-of-network option.
  • Preferred Provider Organization (PPO): This is another network of medical care providers, including hospitals, doctors, and specialists, that coordinate your care. While PPOs have a provider network, beneficiaries may opt for an out of network provider for a higher coinsurance and/or copay.
  • Private Fee-For-Service (PFFS): These plans allow you to visit any Medicare-approved doctor or hospital that accepts both Traditional Medicare and Medicare Advantage terms and conditions. The private healthcare plan, not Medicare, determines how much it will pay and how much your responsibility will be. These plans are the most flexible with regard to who treats you, but doctors and hospitals have the option to decide on a patient-by-patient or visit-by-visit basis whether they’ll accept a patient.
  • Medicare Special Needs Plans (SNPs): These plans are designed specifically for Medicare recipients with chronic health conditions.
  • Medicare Medical Savings Account (MSA): This plan combines a high-deductible healthcare plan and a bank account that you pay to cover your health costs. Your care plan will deposit a certain amount of money each year, and the money pays for Medicare Part A and Part B expenses. When you’ve met your plan deductible, then your healthcare plan pays for future Medicare-covered services. MSA plans do not offer Medicare Part D drug coverage.