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Medicare Part C Eligibility

What is Medicare Part C?

Medicare Part C encompasses Medicare Advantage (MA) plans, which are offered by private insurance companies that are authorized by the government to provide Part C coverage. These plans are required to provide at least the same coverage as Original Medicare (Parts A and B), with the possibility of offering supplementary benefits.

Part C plans are appealing to numerous Medicare beneficiaries because of their affordable premiums and the additional benefits that are not offered by Original Medicare or Medicare supplement plans.

Who is Eligible for Medicare Advantage Plans?

To be eligible for Part C, the same criteria apply as for Original Medicare. Eligibility is determined by the following:

In essence, Part B only covers a portion of medical expenses, outpatient hospital and clinic fees, laboratory work, some home health care, physical and speech therapy, a limited number of drugs, and medical supplies.

  • You are 65 years old or above
  • You have been on disability for at least two years
  • You have been diagnosed with End Stage Renal Disease

Before enrolling in a Part C plan, you must first enroll in Medicare Parts A and B. Additionally, while enrolled in Part C, you must continue to pay the Part B premium; failing to do so will lead to termination of your plan.

It is not possible to have both a Medicare Advantage plan and a Medicare supplement plan simultaneously. While you can switch from a supplement plan to a Part C plan, you may only be enrolled in one or the other.

Types of Medicare Advantage Plans

It is crucial to be aware of the distinctions among the five categories of Medicare Advantage plans.

Health Maintenance Organizations (HMO)

HMOs are among the most prevalent Medicare Advantage plans because of their typically low premiums. In fact, some HMO plans may have a monthly premium of $0. It’s important to note, however, that Part C plans have other associated costs, so a $0 premium doesn’t necessarily indicate a free plan!

HMO plans have a lower premium because they have stringent regulations regarding the healthcare providers you can visit. With an HMO plan, you must receive care from a physician who is under contract with your plan. If you seek medical care outside of your plan’s network, you will not receive coverage except for emergencies.

Moreover, you must designate a primary care physician (PCP) and obtain a referral from them if you need to see a specialist. The specialist must also be within the HMO plan’s network.

Preferred Provider Organizations (PPO)

PPOs also rely on provider networks, but their networks are generally more extensive. Additionally, you will receive coverage even if you receive treatment outside of the network, although you may have to pay a larger portion of the cost. PPO plan members are not required to select a primary care physician (PCP) and may see a specialist without a referral.

PPO premiums are typically higher than HMO premiums. However, some beneficiaries desire more freedom to choose their doctors and receive care from other providers.

An HMO-POS plan is another option. POS refers to Point of Service, and these plans are a combination of the first two types, allowing policyholders more flexibility.

Private Fee-For-Service Plans (PFFS)

PFFS plans differ significantly from HMOs and PPOs and are not as widely used, nor are they available in every state.

Insurance companies that provide PFFS plans compensate contracted providers for offering their services to plan members. The insurance company also determines the cost of services for their members. Individuals with a PFFS plan may visit any contracted provider, but this can become complicated since providers can opt to stop accepting the payment terms at any moment. Consequently, beneficiaries must confirm with their provider before each visit or risk paying the full fee for services.

Medical Savings Account Plans (MSA)

If you’re familiar with Health Savings Accounts (HSAs), understanding how an MSA works is easy. MSA plans are high-deductible plans that require members to pay their deductible before coverage begins, and once the deductible is met, many plans offer 100% coverage for services. MSA policyholders receive a separate savings account with a deposit at the beginning of each year, which won’t cover the full deductible but will help pay for some expenses, and any leftover amount at the end of the year will roll over into the next year.

Medicare Advantage Special Needs Plans (SNP)

So far, we’ve covered four types of Medicare Advantage plans. However, the fifth type, known as Special Needs Plans (SNPs), has unique eligibility requirements that set it apart from the other types.

SNPs are designed to provide targeted healthcare services to specific groups of people who have special needs, such as those with chronic conditions or who reside in certain types of institutions. To enroll in an SNP, you must meet the eligibility criteria established by the plan. These criteria may include having a particular medical condition, living in a certain type of facility, or meeting other specific requirements.

Some of the conditions that SNPs cater to include:

  • Dementia
  • Chronic heart failure
  • Cardiovascular disorders
  • Cancer
  • Diabetes
  • Chronic lung disorders
  • ESRD requiring dialysis
  • Autoimmune disorders
  • and several others

There are various other SNPs available that cater to people residing in long-term care facilities. Furthermore, individuals who are “dual-eligible,” qualifying for both Medicare and Medicaid, can also choose a tailored SNP.

If you require assistance in determining which Medicare plan is suitable for you, you can consult with one of our licensed insurance agents. Our team can evaluate all of your Medicare options and guide you in selecting the most appropriate one based on your requirements.

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