Do I need Medicare Part C?

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Medicare Part C is Medicare Advantage: plans which bring you the coverage of Part A and Part B through a private insurance company. Often these plans will have additional coverage for prescription drugs or dental, hearing, and vision care. Those are some of the major coverage gaps in Part A and Part B, although you could find Medicare prescription drug coverage by adding Part D. Medicare offers no coverage for routine dental, hearing, or vision care.

Another advantage to Medicare Advantage plans are the out-of-pocket limits. While Original Medicare has no out-of-pocket maximum, all Part C plans are required to have them. This becomes especially necessary for people who have regular outpatient visits where they are charged 20 percent of the Medicare-approved amount as cost sharing. Those undergoing dialysis treatment, for example, would have very high out-of-pocket costs, easily passing their deductible within the first treatments.

To be eligible for a Medicare Advantage Plan, you need only be enrolled in Part A and Part B and live within the plan’s service area. You can enroll during Open Enrollment, which falls from October 15 to December 7 each year. If you are already enrolled in a Medicare Advantage plan, you can switch to a different plan or back to Original Medicare from January 1 to March 31. You will want to add a Part D prescription drug plan if you switch back to retain your drug coverage.

Types of Medicare Part C Plans

Medicare Advantage plans come in a few different forms. There are Health Management Organizations, Preferred Provider Organizations, Private Fee-for-Service plans, or Special Needs Plans.

Health Management Organizations (HMOs) operate with networks of providers. You are required to choose a primary care physician from within the plan’s network and will need referrals to see specialists. If you see providers outside of the plan’s network, you will end up paying more.

Preferred Provider Organizations (PPOs) are more flexible than HMOs but also operate with networks. You do not have to have a primary care physician and, in most cases, do not need referrals to see a specialist. You will likely pay more for services from providers outside of the plan’s network.

Private Fee-for-Service (PFFS) plans do not always have networks of providers, but if they do, you will pay less for providers in the plan’s network. You do not have to have a primary care physician or get referrals to see a specialist. You can see any physician who agrees to treat you and accepts your plan’s payment terms.

Special Needs Plans (SNPs) are designed for specific groups of people. There are Chronic Condition, Dual Eligible, and Institutionalized SNPs for people that fall under those categories. There are 15 qualifying severe chronic medical conditions, and the people that join the plan must be at risk of hospitalization due to their severe condition. Dual eligible Medicare and Medicaid beneficiaries qualify for an SNP that may allow zero-dollar cost sharing. Institutionalized members must have lived in a facility for at least 90 days and be receiving an institutional level of care to qualify. These plans have specialists related to the conditions of their members. A primary care physician or care coordinator is required, as are referrals to see specialists except for yearly preventive services. All SNPs have drug coverage for members.

If you are in need of a Part C plan, give Bobby Brock Insurance a call today!

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Justin Brock

President & CEO of Bobby Brock Insurance