MEDICARE PART C

Medicare Part C is most commonly known as Medicare Advantage. Medicare Advantage or “MA” plans are offered by Medicare approved private insurance companies and offer another way to get Medicare Part A and Part B coverage. The MA plan will be administered by private insurance companies that are contracted with the federal government and must follow the guidelines set by Medicare. In most Medicare Advantage Plans you need to use specific network of health care providers. It it very common for most Medicare Advantage plans to include your Part D Prescription Drug coverage.

What does Medicare Advantage cover?

Medicare Advantage will provide all of your Part A and Part B benefits, not including clinical trials and hospice services. MA Plans must cover all emergency, urgent care and almost all medically necessary services that Original Medicare covers. You are still enrolled in Original Medicare under a Medicare Advantage Plan. However, it is important to remember that you will use your Medicare Advantage card to get your Medicare Part A and Part B benefits at all heath care providers and hospitals. You will need to keep your Red, White and Blue Medicare Card in a safe place as it will be required in the event you want to make the change back to Original Medicare.

The MA plan insurer can decide not to cover the costs of services that are not medically necessary under Medicare. However, Medicare Advantage plans may offer certain benefits that Original Medicare doesn’t cover, such as:


  • Dental coverage
  • Vision coverage
  • Caregiver Counseling and Training
  • Housekeeping
  • Prescription Drug Coverage
  • Over-the-counter Benefits
  • Monthly Food Cards
  • Gym memberships

AM I ELIGIBLE FOR MEDICARE ADVANTAGE?

All Medicare beneficiaries are eligible for Medicare Advantage. As long as you are enrolled in BOTH Medicare Part A and B you can purchase a Medicare Advantage plan. You cannot drop Part B. If you do so, you will lose Part C coverage.

Another common questions for Medicare Advantage eligibility is health. MA Plans do not ask any health questions in order to qualify. There are very few restrictions preventing a beneficiary from enrolling in a plan. In order to join a MA plan you must enroll during a valid enrollment period such as the Annual Election Period or “AEP”.

It is best to speak to a licensed Medicare agent such as the Gurus at PGA Insurance to verify enrollment eligibility.

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WHAT DOES MEDICARE ADVANTAGE COST?

Some Medicare Advantage plans have premiums as low as $0. However, this does not mean it is free. Medicare pays a monthly sum to the insurance carrier to provide your care. That’s how premiums can be at passed on at no-cost to you.

WHAT WILL I PAY OUT-OF-POCKET FOR MEDICARE ADVANTAGE

You will pay the plans designated copays and coinsurance cost for each provided service until your plan Annual Maximum Out-of-Pocket or “MOOP”. Every Medicare Advantage plan is required to have an out-of-pocket maximum. This amount is decided by Medicare each year. Currently, the highest an in-network Maximum Out-of-Pocket cost can be is $7,550. Is important to review the Summary of Benefits for each specific Medicare Advantage Plan to get a full understanding of the plans set costs of services and limits.

You will find that each plan differs and many plans that set a lower maximum. This can be a great value because Original Medicare has no out-of-pocket maximum. This means you will be required to pay 20% of your services with no cap or stop loss limit.