Medicare Part C: A Tricky Situation

Medicare has a lot of parts. There are different insurance policies that cover different things and just like employer provided insurance, there are limitations. When people become eligible for Medicare, it's important that they understand exactly what they have signed up for and what is due to them as a Medicare recipient.

What is this?

Medicare Part C is one of the trickiest of all Medicare policies there are to understand. Medicare Part C is another name for Medicare Advantage Plan. This is a name that can confuse those that don't ask enough questions or don't understand exactly what these plans will do to their insurance coverage.

Medicare Advantage Plans are insurance plans that are offered by private companies that Medicare approves of. These companies look at the benefits that Medicare provides and what people are entitled to, create a plan and Medicare approves these plans. When a Medicare recipient signs up for these Advantage Plans, instead of their insurance being administered by Medicare, it is taken over by the private insurance company.

Repeat that? Who has the insurance?

Medicare Advantage Plans are plans that are created by private insurance companies. These plans offer hospitalization (Part A), medical (Part B) and often times prescription drug coverage (Part D) and put in one big insurance policy. Instead of the benefits beginning administered and paid by Medicare, the private insurance company is administering the payments and benefits of those plans. With the change of administration, there are rules that have been changed.

What is so different with an Advantage Plan?

There are many different companies that Medicare has approved of to offer these plans. Many of these companies have seen the benefits that are offered by Medicare and have decided to add benefits to their packages in order to give their customers more opportunities to use their benefits. Some companies decide they want to include vision and dental insurance or even health programs to their packages.

What kinds of Advantage Plans are available?

As with any other private insurance offering, there are different plans that are available. There are differences in all of these plans but the differences may be subtle and hard to see for some. To get a full understanding of these plans, it's best to talk to individual companies to compare their offerings.

The most popular types of Medicare Advantage Plans are Private Fee for Service plans (PFFS) and special Needs Plans (SNP). These plans are different from Original Medicare so it's important to understand the differences and what it means to health care decisions.

Private Fee for Service Plans doesn’t have a specific network of doctors that their customers go to. If they have a regular doctor or group of doctors, they have to accept the payment terms of the company. If they don't want to accept the insurance, they may not treat their patients or the patient will be billed for those services. There are a few plans that have a network of doctors that have already agreed to accept the plan's fees and payment schedule but the insurance company would have to verify that information. Even with some doctors agreeing to accept the insurance, they can still charge more than the agreed upon fee and bill the patient the difference.

Special Needs Plans are not the same as PFFS plans or Original Medicare. A SNP is a plan that is open to those that have specific and chronic medical illnesses such as diabetes, chronic heart failure and many other illnesses like that. When these plans are offered, they normally have a network of doctors that are available for their customers so there may be some customers that have to change their doctors. Although these plans have a network of doctors and hospitals in place, if there is a medical emergency, they can still receive treatment from a non-network facility. These plans have specific benefits that meet the medical needs of the type of illness that they have in addition to the basic medical and hospitalization insurance.

There are some less common Medicare Advantage Plans available as well. There are HMO, Health Maintenance Organization, PPO, Preferred provider Organization Plans as well as Medical Savings Account Plans and HMOPOS. All these different plans have different benefits and rules so before signing up for any of them, there are some things that need to be considered.

Is this better than Original Medicare?

These plans are put together based off what Original Medicare offers. These plans can have a great effect on their customers or they can make customers dread going to the doctor's office. There are many things that are beneficial to people that get these plans, such as additional services, less out of pocket expense, etc. There are some people that don't benefit at all from the plans because of the limitations and additional out of pocket expense.

As with any insurance, these plans aren't meant for everyone to take advantage of. Medicare Advantage Plans are plans that have to meet the needs of the customers and are not meant to make them miss valuable and necessary medical treatment. Before anyone switches to an Advantage Plan, they should think of the care they require, special visits and prescription drug needs and compare the costs and benefits with the Medicare Part C plan that is being offered.

What are the costs of these plans?

When Medicare beneficiaries decide to enroll into an Advantage plan, they forward the Medicare Part A and B premiums to the company that will be administering those benefits. The company that is administering the Advantage plan benefits will have set the premiums for their plans. If there is a cost over what Medicare is forwarding, the difference will have to be paid by the customer. There are some plans that have no additional premium costs and others that have additional costs. That is determined by each company.

When people sign up for these plans, it is important to ask if there are any deductibles that have to be met and what are the copays for doctor, hospital and prescription drugs. There may be additional charges for not using a network provider and the different types of care that is given on a specific visit. When people are signing up for a Medicare Advantage plan, it is important to ask detailed questions because not doing so can cost the customer more money than they intended to spend.

Is this a good plan or not?

To say that Medicare Part C plans are not a good idea would be wrong. These plans have great benefits to those that can use the services that are offered. Before switching to these plans, Medicare recipients should consider the following:

  •         Is your current doctor apart of the network?
  •         Are your current medications covered in the formulary?
  •         Do you have a preexisting condition that may not be covered?
  •         Are you able to see a specialist if necessary?
  •         What are the additional costs of the plan? Copays? Premiums?

All these questions and more should be asked before switching to an Advantage plan.

There are many people that have been misled by an insurance agent into signing up for a Medicare Advantage plan just because it benefits the agent. Insurance agents have a wealth of knowledge about these plans at their disposal and they should be able to answer any questions posed to them. If the company representative or insurance agent can't answer a specific question, don't sign up for the plan.

If at any time an insurance agent begins to pressure a Medicare beneficiary into signing up for these plans, they should be reported immediately to Centers for Medicare and Medicaid Services for predatory practices. Insurance is too important to be pressured into so when it doesn't feel right, don't sign the papers and end the discussion.

May. 7 12'

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