Medicare Part C

Medicare Part C (Medicare Advantage) Explained
Isolated Letter C
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What is a Medicare Part C plan?

A Medicare Part C (also called Medicare Advantage) plan is a private insurance policy that replaces Medicare Part A and Part B. 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.

Medicare Part C plans are regulated by the federal government, which requires every plan to provide at least the same coverage as the government-run Medicare Parts A and B. Medicare Part C plans eliminate some Medicare co-payments and deductibles, just as a Medigap insurance policy does. And like Medigap policies, Medicare Part C plans provide coverage for some gaps in Medicare Part A and Part B coverage. For that reason, if you enroll in a Medicare Part C plan, you don't also need to buy a Medigap policy.

Keep in mind that each Medicare Part C plan is slightly different, depending on what that plan's private insurance company chooses to offer beyond basic Medicare.

Why look at Medicare Part C plans? The slightly broader coverage than Medicare Part A and Part B is one reason, but the main benefit is cost. Total out-of-pocket expenses with a Medicare Part C plan are usually lower than expenses with the combination of traditional Medicare Parts A and B plus a Medigap insurance policy. (But there are also real disadvantages with Part C plans; see What are the disadvantages of Medicare Part C plans?)

Who's eligible for Medicare Part C coverage -- and what types of plans are included?

If you're eligible for Medicare Part A and Part B, you can join a Medicare Part C plan instead. To join one, though, the plan's insurance company must be offering it in the region -- usually a county or group of counties -- where you live. And that particular plan must be accepting new enrollees.

Medicare Part C plans come in two basic types:

  • Managed care
  • Fee-for-service

_ Medicare Part C managed care plans: _ There are several kinds of managed care plans, but they all operate under the same basic rule: You get full coverage only if you see a healthcare provider who is a member of the plan's "network." The most common, least expensive, but most restrictive Medicare Part C managed care plans are health maintenance organizations (HMOs). There are also Medicare Part C preferred provider organizations (PPOs) and Part C HMOs with a point-of-service (POS) option that add certain variations to basic HMO rules.

_ Medicare Part C fee-for-service plans: _ A Medicare Part C fee-for-service plan works differently than a managed care plan, without the same "network" limitation of managed care. Instead, a Medicare Part C fee-for-service plan allows you to see any provider, but only if that provider accepts the plan's restrictions on the particular medical service and accepts the amount the plan is willing to pay for that service.

How does a Medicare Part C managed care plan work?

Medicare Part C managed care plans are required to cover any medical service that would be covered under Medicare Part A and Part B. Also, many Medicare managed care plans add some coverage (though usually not much) that isn't covered by Part B. Each plan decides what extras it will offer (see "Do Medicare Part C plans offer broader coverage than Medicare Part A and Part B," below).

With Medicare Part C HMO plans, there are important restrictions on how you get your care:

  • To get coverage from a Medicare Part C HMO plan, you can obtain care only from doctors, hospitals, and other healthcare providers who belong to the HMO's official "network" -- meaning providers who are under contract with the HMO.
  • A Medicare Part C HMO plan won't pay for care by a specialist unless referred by your HMO-network primary care physician.
  • Under a Medicare Part C HMO plan, you might not be covered for certain kinds of care unless the plan approves that care in advance.
  • You have limited rights to appeal a decision made by the Medicare Part C plan with regard to the care they won't cover.

Two other types of Medicare Part C managed care plans, slightly different from HMOs, are available in some places. One is an HMO plan with a point-of-service (POS) option; the other is a preferred provider organization (PPO) plan. With either of these Medicare Part C plans, you can see a provider outside the plan's network, or see a specialist without first getting a referral -- but the plan will pay a smaller amount of the bill. These plans are less common than Medicare Part C HMOs and might not be available where you live.

How does a Medicare Part C fee-for-service plan work?

Medicare Part C fee-for-service plans don't restrict your choice of doctors to a specific network list, the way managed care plans do. With a fee-for-service plan, you can go to any doctor that participates in Medicare. And if your doctor refers you to a specialist, you don't need the fee-for-service plan's permission in order to get coverage. But Medicare Part C fee-for-service plans have significant restrictions of their own, which might make a Part C managed care plan better for you if your primary care physician and most other doctors in your area belong to that managed care plan.

Restrictions imposed by Medicare Part C for fee-for-service plans:

  • For each medical service you want covered, the doctor or other provider must accept whatever limits the plan places on the treatment; and the doctor must agree to whatever payment the plan offers. If a doctor doesn't accept the plan's terms and payment amount, the plan won't cover your care from that doctor.
  • Even though you've received covered care once, there's no guarantee that the next time the plan will approve the same care or offer the provider the same payment. Similarly, a doctor isn't required to accept the plan's terms again, just because he or she did so before. So, with a fee-for-service plan, you won't know until the time comes whether you'll be able to get covered care from a particular doctor or other provider.
  • Some Medicare Part C fee-for-service plans require you to pay a co-payment of up to 15 percent of the amount the plan approves for the particular service.
  • Some fee-for-service plans have provider networks, just as managed care plans do. With these plans, you're not restricted to network doctors or other providers, but you'll pay a higher co-payment if the provider isn't in the plan's network.

Do Medicare Part C plans offer broader coverage than Medicare Part A and Part B?

With most Medicare Part C plans, you can get slightly broader coverage than with basic Medicare Part A and Part B. For example, almost all Medicare Part C plans cover routine physical exams. Some offer short-term custodial care -- meaning nonmedical help with activities of daily life -- in a nursing facility or at home, which traditional Medicare doesn't cover. Also, some plans provide coverage for eye and hearing care, expanded physical therapy, chiropractic, and various kinds of preventive care.

What do enrollees typically pay for a Medicare Part C plan?

Some Medicare Part C plans charge no premium. However, you still have to pay Medicare Part B's monthly premium; Medicare uses these funds to provide financial support to the Medicare Part C plans. Other Medicare Part C plans charge their own added monthly premium. This added premium, though, is usually substantially less than what you'd pay for a Medigap supplemental insurance policy.

With a Medicare Part C plan, you don't have to pay Medicare Part A and Part B deductibles and co-payments. But the Medicare Part C plans have their own deductibles and co-pays. So, when considering a plan, be sure to investigate these payments as well as the monthly premiums.

What are the disadvantages of Medicare Part C plans?

Although Medicare Part C plans have both cost and coverage benefits, they also have serious drawbacks. With Medicare Part C managed care plans, the limits on which providers you can see may be the most important. If you want to consult a doctor who's not in the plan's network, you'd have to pay some or all of the cost yourself. (This is less of a problem with large managed care plans, especially in urban areas. That's because most doctors participate in the networks of the big managed care plans.)

If you're considering a Medicare Part C managed care plan, one of your first steps should be to see if your regular doctors are in the plan's network. If not, and you want to stay with your doctors, that plan isn't a good one for you.

If you're considering a Medicare Part C fee-for-service plan, ask your regular doctors if they have any experience with the plan, and if so whether they usually accept the plan's terms and payments. If not, that plan may not be right for you.

Another problem with a Medicare Part C managed care plan can arise if you want to see a specialist. If the Medicare Part C managed care plan itself decides the specialist isn't necessary, you'd have to pay for the visit out of your own pocket. Likewise, if the plan decides certain care not provided by your primary care doctor -- for example, extensive physical therapy or home healthcare -- isn't necessary, the plan won't pay for it even if a doctor prescribes it.

There might also be a problem with a Medicare Part C plan if you often spend time in more than one place -- traveling, at a second home, or staying with other family members. Coverage by a Medicare Part C plan is usually limited to the region where you live. Outside the region, you'd be responsible for some or all nonemergency bills.

Finally, there's the risk that you'll be dropped from a Medicare Part C plan. Over the past few years, many people with a Medicare Part C plan have suddenly found themselves without coverage when the plan decided to stop operations in their region. Plans regularly pull out of areas where their profits aren't making them happy. If you're dropped in this way, you aren't completely out of luck -- some other options are available -- but scrambling for other coverage can be difficult.

Where can I get more information about Medicare Part C plans?

The official Medicare website has a feature called the Medicare Personal Plan Finder that can direct you to Medicare Part C plans available where you live. It also gives information about each plan's general terms.

But to know exactly what a plan offers and what all its costs and restrictions are, you have to contact the issuing insurance company itself and carefully read its written materials. You can get help deciphering plan materials by contacting your [local State Health Insurance Assistance Program (SHIP) or Health Insurance Counseling and Advocacy Program (HICAP), which provide free expert assistance.

Joseph L. Matthews

Joseph Matthews is an attorney and the author of numerous books, including Social Security, Medicare, and Government Pensions, Long-Term Care: How to Plan and Pay for It; How to Win Your Personal Injury Claim; and The Lawyer Who Blew up His Desk. See full bio

about 3 years, said...

There are some significant errors and omissions in this article concerning public Part C Medicare health plans, not the least of which is that Part C is not private... it is Part -- with an upper case P -- of public Medicare. When the Census Bureau counts people's insurance policies, it correctly counts Part C as public. Probably the major substantive problem with this article is that under benefits this articles does not mention that all public Part C Medicare health plans include an annual out of pocket spend limit. Original Medicare Parts A and B do not include such a limit and only some Medigap plan types -- not available in all states -- include such a limit. The author is correct however that Part C is not for everyone. If your favored provider or providers does/do not accept it... end of subject. If you do not like HMOs or PPOs, forget Part C (the PFFS programs mentioned here are almost non existent in 2015). If you are a snowbird, stick with Medigap.

over 3 years, said...

i have a 79 year old sister that nees 24 hr care. i work full time she is in the hospice hospital now with colon cancer, terminal illness. can i move her to a nursing home for a short term under medicare

over 4 years, said...

Wow. Thanks to Joseph Mathews I have a tiny bit of hope that I can find the answer to my question. I live in Ulster County and am seeking a Medicare choice that might cover acupuncture that may be my only hope of cure for my illness. Any suggestions for a pathway to this information would be ever so appreciated. With much gratitude, Phyllis

about 5 years, said...

Was looking for a bit more detailed look at Part C Advantage Plans. But, I now know a lot more about them than before.

almost 6 years, said...

Looking for information on medigap insurance, AARP, and if would be a good choice, if I have to have my DH go to a facility?

about 6 years, said...

make things easier to understand and not so confusing.

over 6 years, said...

just keep me in your prayers that GOd will provide with the way things are goinfg now it's just getting worst and know one wnts to help or even give you any information to help you out. someone email me with worthly information that will help me help my father. thanks

over 6 years, said...

i need some help financially and some knowledge on taking care of my father who i 98 years old and has alzhemeirs and is now wearing depends he doesn't know how to use the bath room /toliet anymore i really need someone to help me with this situation and i will not put him in a home but i still do ned some time to myself and still take care of him too.

almost 7 years, said...

Yes, again another helpful article. I learned the difference between A, B, C plans for Medicare. Thank you

over 7 years, said...

this website helped me very much. thanks

over 7 years, said...

Please send me amount of medicare c.

over 7 years, said...

Helpful but I wish you had discussed who PAYS FOR medicare advantage plans. And also discuss whether they are worth the amount of taxpayer money that goes to private insurance companies rather than medicare itself or medicare providers.

about 8 years, said...


over 10 years, said...

It will take me several reads to get through all this info, but it's very helpful in sorting out fact from the fiction pushed at us by health insurance companies.