Medicare Part C: Your Complete Guide to a Medicare Advantage Plan
Medicare Part C, also known as Medicare Advantage Plan, is provided by private insurance companies and combines the coverage of both Part A and Part B into a single health care plan. Under a Medicare Advantage Plan, you may have to choose from a network of doctors, hospitals, and other service providers to receive the benefits of the plan.
Otherwise, you could face a higher cost. Plans often have a monthly premium and co-payments for services. Premiums may or may not include the cost of Part B coverage.
Video: Who Qualifies for Medicare?
Typically, you can join a Medicare Advantage Plan if:
You already have Medicare Part A and Part B
- You live in the plan’s service area.
- You do not have End-Stage Renal Disease.
There are four different types of Medicare Advantage Plans available:
Health Maintenance Organization (HMO) plans require you to receive services from doctors and hospitals that are within the HMO network. The plan doesn’t cover services received outside the network except on for emergency care and out-of area urgent care and dialysis (at a higher cost). You must choose a primary care physician and you are unable to receive services from specialists without a referral from your primary care physician. Most HMO plans include prescription drug coverage.
Preferred Provider Organization (PPO) plans also have a network of doctors and hospitals you can choose from. Unlike HMO plans, PPO plans cover some part of the cost of services received from out-of-network providers, though you will share a higher portion of the cost. You do not have to select a primary care physician and you do not need a referral to see a specialist. Most PPO plans include prescription drug coverage.
Private Fee-for-Service (PFFS) plans do not have a network of hospitals and doctors for you to choose from. Instead, you can choose any Medicare-approved doctor or hospital as long as they agree to accept the payment terms of the plan. PFFS plans have a predetermined rate that will be paid to doctors and hospitals for covered services. Then, service providers decide whether they will accept those rates or not. Under a PFFS plan, you do not have to choose a primary care physician and you do not need a referral to see a specialist.
Medicare Medical Savings Accounts (MSAs) have two parts. First, there is a health plan with a high deductible. Second, there is a medical savings account. Each year, Medicare deposits a certain amount into the savings account to cover your qualified medical expenses. You’re not allowed to contribute to the account. Under a MSA plan you have to meet a high deductible $10,500 before the plan will cover health care costs. Prescription drug coverage (Part D) must be purchased separately. Though you can choose any doctor or hospital, some MSA plans have a list of service providers who will provide lower cost medical services.
Advantages of Medicare Part C
When you choose Original Medicare, that is Part A and Part B coverage, there is usually a gap between what the plan pays and the amount the services actually cost. You are responsible for paying that gap out of pocket or for obtaining Medigap insurance to help offset the cost. Medicare Part C eliminates this gap of coverage and the need for Medigap insurance. Not only that, Medicare Advantage Plans often provide coverage benefits beyond that provided with Part A and Part B separately. Most Medicare Advantage Plans include prescription drug coverage, so you don’t have to purchase Medicare Part D to help offset the cost of prescription drugs.
What’s Covered Under Part C
Medicare Part C coverage must include at least those services that are covered by both Part A and Part B. Additional coverage may be available and varies by plan provider.
Blood
Part A covers blood after the first 3 pints.
You pay for the first 3 pints received during a calendar year.
If the blood is donated from the blood pay, there is no charge.
Home Health Services
If your doctor orders it, you can receive part-time skilled nursing care, physical therapy, occupational therapy, or speech-language pathology.
Medical social services, home aide services, medical supplies, and medical equipment may be included.
The first 100 visits after a hospital stay are covered.
To qualify, you must be homebound, that is, it takes a great deal of effort for you to leave the home.
Hospice Care
Hospice care for individuals who have a terminal illness and have been doctor-certified to live only 6 months or less is covered.
Hospice care can be given in the home by a Medicare-approved hospice.
A short stay in an approved facility may be covered.
Inpatient respite care is provided, including up to 5 days each time.
Drugs, medical services, and nursing services are covered.
Unrelated health problems may be covered.
Hospital Stays
A hospital stay in a semi-private room including means, nursing, drugs, hospital services, and medical supplies.
A private room may be covered if the doctor deems it medically-necessary.
Skilled Nursing Facility Care
Up to 100 days in a benefit are covered after a minimum 3-day inpatient hospital stay.
The hospital stay must have been for a related illness.
Coverage includes a semi-private room, including meals, nursing, rehabilitative services, and medical supplies.
Your doctor must state that you need skilled care on a daily basis.
Abdominal Aortic Aneurysm Screening
To have this screening covered, you must receive a referral during your initial physical exam.
A minimum of one screening is covered.
Ambulance Services
Emergency ground transportation when being transported in another vehicle would put your health at risk.
You may receive coverage for airplane or helicopter emergency transportation when you require more immediate transportation.
Non-emergency transportation may be covered under doctor’s orders.
Ambulatory Surgical Centers
Facility fees when you have an approved surgical procedure conducted are covered.
You will be responsible for paying any charges not covered by Medicare.
Bone Mass Measurement
This coverage includes at least one preventive service every 24 months unless it is medically-necessary for you to receive it more often. You must meet certain criteria to have the services covered.
Cardiovascular Screenings
Every 5 years you may have your cholesterol, lipid, and triglyceride levels.
Chiropractic Services
You can receive services to fix a subluxation which occurs when the bones in your spine have moved out of position.
Clinical Laboratory
Coverage includes services that are performed in a clinical laboratory.
This includes things like blood tests, urinalysis, and screening tests.
Clinical Research Studies
If you participate in a qualifying research study, Medicare covers some of the costs, e.g. doctor visits and tests.
Colorectal Cancer Screenings
If your doctor orders is you may receive certain tests to help find precancerous growths
Fecal Occult Blood tests may be conducted annually for those over 50.
Flexible Sigmoidoscopy can be conducted every 48 months for those over 50, or 120 months for those not at high risk.
Colonoscopy can be conducted every 120 months or 24 months for those at high risk.
Barium Enema can be conducted once every 48 months for those over 50 or 24 months for those at high risk.
Defibrillator
If you have been diagnosed with heart failure, this service is covered.
Diabetes Screenings
Covered if you have risk factors for diabetes including high blood pressure, abnormal cholesterol and triglyceride levels, obesity, or high blood sugar.
Coverage includes up to two screenings annually if you are over 65, overweight, have a family history of diabetes, have a history of gestational diabetes, or delivered a baby weighing more over 9 pounds.
Diabetes Self-Management Training
If your doctor orders it, this service is covered.
Diabetes Supplies
Covered supplies include blood sugar testing monitors and test strips, lancets and lance devices, blood sugar control solutions, some therapeutic shoes, and insulin when used with an insulin pump.
Doctor Services
Medically-necessary services and certain preventive services are covered. Routine physicals outside the initial Medicare physical are not covered.
Durable Medical Equipment
Certain equipment is covered as ordered by your doctor.
This includes things like wheelchairs, walkers, hospital beds, and oxygen equipment.
You may have to rent the items first.
Emergency Room Services
You are responsible for paying a co-payment for the emergency room visit.
Eye Exams
People with diabetes can receive an annual eye exam to check for diabetic retinopathy.
Eyeglasses
If you have a cataract surgery that implants an intraocular lens, you can receive one pair of eyeglasses with standard frames.
Federally Qualified Health Center Services
A range of outpatient preventive services and primary care is covered.
Flu Shots
The shot is covered once each flu season during the fall and the winter.
Foot Exams and Treatment
Those with diabetes nerve damage and certain other conditions are covered for this service.
Glaucoma Tests
You can receive glaucoma testing once a year if you have diabetes, a history of glaucoma, are an African-American over 50, or are a Hispanic over 65.
Hearing and Balance Exams
These exams are covered if ordered by your order to determine medical treatment.
Hearing aids and exams are not covered.
Hepatitis B Shots
This shot is covered if you have hemophilia, End-Stage Renal Disease, or a condition that lowers your resistance to infection.
Your doctor can determine if you have other factors that increase your risk for Hepatitis B.
Home Health Services
Certain medically-needed services are covered including part-time nursing care, part-time physical therapy, speech-language pathology, or occupational therapy.
Your doctor must order the services.
The services must be provided by a home health agency that has been Medicare-certified.
Kidney Dialysis Services and Supplies
This service is covered for people with End-Stage Renal Disease when ordered by a doctor.
Mammograms
Women over 40 can receive a mammogram once every 12 years.
Women between 35 and 39 can receive a single mammogram.
Medical Nutrition Therapy Services
If you have diabetes or kidney disease, your doctor may refer you to receive medical nutrition therapy.
Mental Health Care
Covered services include doctor, psychiatrist, clinical psychologist, and clinical social worker visits.
Certain limits and conditions apply.
Occupational Therapy
Your doctor must certify that you need certain evaluation and treatment to return to normal activities.
Outpatient Hospital Services
Coverage includes services you receive on an outpatient basis that are part of a doctor’s care.
Outpatient Medical and Surgical Services and Supplies
Certain approved procedures are covered including X-rays, casts, or stitches.
Pap Tests and Pelvic Exams
Screenings are covered once every 24 months.
Women at high risk including those in child-bearing age who have had abnormal exams may receive exams every 12 months.
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Physical Exam
Medicare covers a one-time physical exam to review your health.
To have Medicare cover its share of the exam cost, you must receive this exam within the first 12 months of receiving Part B coverage.
Physical Therapy
If ordered by your doctor, Medicare covers evaluation and treatment for injuries that change your ability to function.
Pneumococcal Shot
This shot is typically given once during a lifetime and helps prevent certain types of pneumonia and other infections.
Practitioner Services
Coverage includes those services provided by nurse practitioners and physician assistants.
Prescription Drugs
Certain drugs that are received in hospital outpatient care, those injected in a doctor’s office, some oral cancer drugs, and some types of durable medical equipment are covered.
Prostate Cancer Screenings
Men over 50 can receive a screening once every year.
Prosthetic/Orthotic Items
Certain items like arms, legs, back and neck braces are covered when a doctor orders them.
Rural Health Clinic Services
Coverage includes a range of outpatient primary care services received at one of these clinics.
Second Surgical Options
When surgery is an emergency, Part B covers some second and third options.
Smoking Cessation
If you are diagnosed with an illness that was caused or is complicated by the use of tobacco, you may receive 8 face-to-face visits during a year.
Speech-Language Pathology Services
When your doctor orders it, you may receive treatment to help regain and strengthen speech and language skills.
Surgical Dressing Services
Coverage includes services that are needed to treat a surgical or surgically-treated wound.
Telemedicine
Under certain conditions, Health services given over the phone, by computer, or through the television are covered.
Tests
Certain tests like X-rays, MRIs, CT scans, and EKGs are covered.
Transplants and Immunosuppressive Drugs
Under certain conditions, doctor services are covered if they are given in a Medicare-certified facility. Heart, lung, kidney, pancreas, intestine, liver, bone marrow, and cornea transplants may be covered. Immunosuppressive drugs are covered if the transplant was paid for my Medicare.
Travel Health Care
On an exception basis, you may receive health care when you travel outside the U.S. if you are on board a ship within the U.S. territorial waters.
Urgently-Needed Care
Sudden illnesses or injuries that are not medical emergencies are covered