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What is a Medicare Part C? How does Medicare Part C Work?
Medicare Part C combines Part A and Part B with option to combine Part D into one plan. Combining Part A & B is (called Medicare Advantage or an MA Plan). When three parts A, B, and D are combined these plans are referred to as MAPD (Medicare Advantage Prescription Drug Plans). Organizations offering these types of plans have a Federal government contract with Medicare. These plans are administered through a private insurance policy that replaces Medicare Part A and Part B and assigns all rights to the insurance carrier. In other words, if you enroll in a private Medicare Part C plan, you no longer receive coverage through Medicare Part A or Medicare Part B. However you are still part of Medicare program.
All Part C programs offered by private insurance carriers must be approved annually with CMS - Centers for Medicare and Medicaid Services to ensure the plans meet a minimum threshold of benefits. These Medicare Advantage Plans must be equal to or better than Original Medicare. Each plan is tailored as a cost share program pay as go with an out-of pocket maximum that limits expenses any one year. Some gaps in Medicare Part A and Part B are there by covered and as a result you would not need a Medigap policy. You can only be on one of these plans at a time and plans that are offered are done on a county by county basis in each state. You are unable to purchase a Medigap policy at the same time you are enrolled in a Medicare advantage plan.
Medicare Part C -- and what types of plans are included?
Medicare Part C Advantage Plans come in two basic forms; Managed Care Plans and Private Fee for Service Plans
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1. Medicare Part C Managed Care Plans have several variations or combinations of plan types. No matter what type of plan you have, to receive 100% coverage of paid benefits you must follow the guidelines of the individual plan. Type of Managed Care Plans are (HMO) Health Maintenance Organization; (PPO) Preferred Provider Organization with and without (POS) Point of Service Network
• HMO most restrictive type of manage care
• HMO lowest premiums and out of pocket expenses
• HMO plan with a point-of-service (POS) option, can see provider without a referral
• PPO has higher premiums, has Out of Network Options at Higher Co-pay and Coinsurance
• Limited Rights to Appeal Decisions
• HMO has network of providers, doctors and hospitals in your area. Referrals are needed for Specialist and may be denied or take longer for approvals
2. Medicare Part C is a Fee- for- Service Plan that closely resembles Original Medicare. Has the most flexibility of all manage care plans. Can see any provider who accepts Medicare.
• May go to any doctor who will accept the conditions and terms of the plan
• At point of service, doctor can determine whether to see you or not based on plans restrictions and reimbursements of service.
• Highest Premiums of all plan types
• Greatest Flexibility
• Larger Co-pays and out-pocket expenses
Biggest Benefits of Medicare Advantage Plans Part C are:
1. Premiums are lower than most Medicare Supplements- Some Plans are Zero Premium but most now charge a premium.
2. Medicare Part A Hospital Deductibles and Coinsurance are replaced with daily co-pays and maximum out-of- pocket costs in any one year.
3. Medicare Part B Deductible and Coinsurance are also replace with pre determined Doctor Co-pays a procedural co-pays or service related co-insurance with maximum combined out-of pocket expenses in any given year.
4. Some additional services provided at little or no cost;
• preventive dental,
• vision eye wear allowance,
• hearing aid allowance,
• physical fitness, exercise with facility membership plans
Biggest Disadvantage to Medicare Advantage Part C
1. Limiting your access to Doctors
• by networks , HMO PPO or PFFS
• Doctors willing to provide services (Some will not see PPO patients even out of Network Patients)
2. Unable to Budget Health Care Needs
• Doctor visits and hospital stays are not always schedule events; Co-Pays and Deductibles can be Costly when figured together with premiums.
• If you are healthy, Medicare Advantage Part C plans can be a tremendous saving. If you are not healthy, maybe, not so Much!
3. Plans Change Annually and Providers Come and Go
• Constant battle of up dating yourself each year on what is covered and how much the co-pays or coinsurance will be.
Who's eligible for Medicare Part C Coverage?
Anyone who has Medicare Part A and B can enroll in a Medicare Advantage Plan provide they have not been diagnosed with End Stage Renal Disease.
Medicare Beneficiaries are limited by certain times of the year when enrollment can take place. Enrollment periods include (IEP) Initial Enrollment Periods, (AEP) Annual Enrollment Period, and (OPE) Open Enrollment Period and (SEP) Special Election Period.
IEP - new to Medicare or newly enrolled into Medicare Part B. Aging In or new to Medicare beneficiaries have 3 months prior to birth month of age 65, actual birth month and 3 months after birth month to enroll in a Medicare Advantage Plan. This is a total of 7 months to familiarize themselves with Medicare and their options. Those born on the first day of the month their effective date can begin on the first day preceding the month of their 65th birthday.
Annual Enrollment Period – November 15th to Dec 31st of each year. May change more than one time during this period.
Open Enrollment Period – January 1, to March 31st of each year. May change one time to a like plan and then you are locked in to that plan until following Jan. 1st effective date.
Special Election Period- Many types of Special Election Periods most common to include; Low Income or Special Needs; determined by state level Medicaid, Moving into a new Area, and Discontinuation of Medicare Advantage Plans.
Future of Medicare Part C and the Advantage Plans
With the passage of the New Health Care Reform Bill many changes can be expected in the Medicare Advantage arena. Approximately 241 billions dollars are coming out of the Medicare over a 10 year period and redistributed to the nationalized health care plan. Majority of this money will be taken away from the Medicare Advantage programs starting in 2011. Experts in the industry say the future of Medicare Part C plans is dismal. Each year the private insurance companies will receive less money adjusted for medical costs and inflation than the year before. With less money to work with expect a number of things to happen very quickly starting in 2011.
• Reduction and or elimination of additional benefits dental, vision, hearing aids, and fitness programs.
• Higher Co-Pays and stricter guidelines
• Increase in Premiums for all type of Plans.
• Shifting More of the Cost Share to the Medicare Beneficiary
Grim predictions come from experts who are managing these plans and providing the cost accounting benefit analysis. All the industry insiders we speak with indicate there will be less companies participating in this market driving premiums higher and benefits lower. We believe the introduction of the additional Medigap Plans M and N in June 2010 was no coincident as these plans are design to pick up more of the Medicare Advantage market with lower premiums offered than traditional Medigap plan policies. See Medicare Supplement Plans M and N
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