What is Part C?
Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. Most Medicare Advantage Plans include drug coverage (Part D). In most cases, you’ll need to use health care providers who participate in the plan’s network.
These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services. Some plans offer non-emergency coverage out of network, but typically at a higher cost. Remember, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services.
Basic Medicare Advantage Rules
If you are deciding between Medicare Advantage and Medigap, you’ll want to consider
some of the rules before you enroll.
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You must be enrolled in both Medicare Part A & B and live in the plan service area. Some people think they can drop Part B if they enroll in Medicare Advantage. That is incorrect If you drop Part B while enrolled, you will immediately be disenrolled from your Medicare Advantage plan.
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Use network doctors and hospitals for the lowest out-of-pocket costs. Plans may have HMO or PPO networks. Most Medicare HMO plans do not cover anything out of network except emergencies. In PPO networks, seeing a provider outside the network will result in higher spending for you.
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Advantage plans may require prior authorization for certain procedures
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You may need to obtain a referral from your primary care physician before seeing a specialist on many HMO plans
Put your red, white, and blue Medicare card in a safe place.
Do not give it to any of your healthcare providers.
If they bill Medicare, those bills will be rejected because they should have
been sent to your Medicare Advantage insurance company for processing.
You must direct your providers to bill your Medicare Advantage plan.
People who enroll in Advantage plans for Medicare are agreeing, for the rest of the calendar year,
to be covered by the plan instead of Original Medicare.
Medicare Advantage Enrollment Periods
Medicare Advantage plans have lock-in periods. You can enroll in one during the Initial Enrollment Period when you first turn 65. After that, you may enroll or dis-enroll only during certain times of the year. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year. You may only dis-enroll from an Advantage plan during certain times of the year unless you qualify for a special enrollment period due to a specific circumstance.
The Annual Election Period in the fall is the most common time to change your Medicare Advantage plan. This period runs from October 15th – December 7th each fall.
Changes made to your enrollment will take effect on January 1.
If you decide to leave an MAPD and return back to Original Medicare, you must notify your Medicare Advantage plan carrier. Otherwise, Medicare will continue to show that you are enrolled in the Advantage plan instead of Medicare.
Medicare Advantage Open Enrollment Period
Some people join Medicare Advantage plans without doing any research about how these plans work or speaking with an agent who can advise them. Therefore they don’t know about all of these rules. They may find themselves enrolled in a plan that their doctor doesn’t accept or that doesn’t include one of their medications. This happens most often in January after a person has used the Annual Election Period to join a Medicare Advantage plan.
For this reason, Congress designed the Medicare Advantage Open Enrollment Period that runs from January 1st – March 31st each year. During this time, you can disenroll from any Medicare Advantage plan and return to Original Medicare. You will be allowed to add a standalone Part D drug plan.
Unfortunately, this does not guarantee that you can return to the Medigap plan you had before. Unless this was your first time ever in a Medicare Advantage plan, then you will usually have to answer health questions and go through medical underwriting to get re-approved for Medigap. Consider this before dropping any Medigap plan to go to Medicare Advantage.
Your other option during the Medicare Advantage Open Enrollment Period is to change from your current Medicare Advantage plan to a different Medicare Advantage plan.
Please be aware that you can only use this period once per calendar year.
Other Considerations about Medicare Advantage
Be sure to carefully consider these things before joining a plan:
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Not all hospitals and doctors accept Advantage plans. Ask your agent to help you verify whether your medical providers accept the plan you are interested in.
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Advantage plan benefits may change every year. In September, you will receive a packet from your Part C insurance company telling you what is changing. The plan’s benefits, formulary, pharmacy network, provider network, premium and/or co-payments, and co-insurance may change on January 1 of each year. Will you be diligent enough to review your annual packet and communicate with your agent if you have concerns about the changes?
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Your enrollment is generally for the entire year. You may only dis-enroll from an Advantage plan during certain times of the year. If you decide in April that you don’t like the plan, you will have to wait until the following annual election period begins in October in order to change your plan unless you qualify for a special election period.
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If you enroll in one right out of the gate at age 65, you need to be sure you want this coverage long-term. Your open enrollment window to get a Medigap plan with no health questions ends 6 months past your Part B effective date. You might not be able to get a Medigap plan later if you have health conditions because applying for Medigap later will require you to answer medical questions. You can be turned down for Medigap at that point if you are not healthy enough to qualify.
Frequently Asked Questions
Do you pay the Part B premium with Medicare Advantage?
Yes, you must first enroll in both Medicare Parts A and B before you are eligible to add on an Advantage plan. This is true even if the Advantage plan itself has a $0 premium. You will still pay your Part B premium to Medicare every month.
How can Medicare Advantage plans be free?
Medicare Advantage plans are definitely not free. Some plans have a $0 premium. This means you pay no premium for the plan itself, but you will still pay the Part B premium to Medicare, and you will pay deductibles, copays, and coinsurance as you use your benefits. When you enroll in a Medicare Advantage plan, Medicare pays the Advantage plan insurance company a monthly fee to take on all of your medical risks. That is the reason why some plans can offer you a $0 premium – they are already getting paid by Medicare on your behalf.
What is a MAPD?
A MAPD is a Medicare Advantage Prescription Drug plan. This would be an Advantage plan that includes drug coverage. Advantage plans that do not include drug coverage are abbreviated to MA.