Electing and enrolling in a healthcare program is a vital aspect of every individual’s livelihood. Acquiring sensible health insurance allows individuals to be fortified against unexpected medical expenses, as well as maintaining robust health. Health insurance also covers those individuals during illnesses or accidents, by paying for the majority of medical costs, depending on the plan.
However, it is estimated that over 20 million individuals still don’t have health insurance, with the costs accounting for the predominant rationale. Consequently, numerous individuals opt to enroll in an accessible, yet economical healthcare plan such as Medicare.
What Is Medicare?
Medicare is a federal government healthcare program operated by the Centers for Medicare and Medicaid Services, CMS, which provides healthcare to millions of individuals in the United States. It is partially funded by Social Security and Medicare taxes that individuals pay on their income taxes, the premiums paid by Medicare-enrolled beneficiaries and the federal budget. Medicare is only attainable for individuals over the age of 65, specific younger individuals with disabilities, individuals with End-Stage Renal Disease(ESRD), and individuals receiving Social Security Disability Insurance (SSDI).
After Being Enrolled
Once eligible and successfully enrolled in Medicare, those individuals must elect whether they wish to receive their benefits through Original Medicare, which is the conventional fee-for-service program directly offered through the U.S. federal government, or through a Medicare Advantage Plan, which is a type of private insurance offered by companies who coincide with Medicare.
The Main Parts Of Medicare
Medicare also has four parts, A, B, C, and D, while each part is associated with and covers specific healthcare services. Medicare Part A covers inpatient hospital stays, care in a skilled nursing home or facility, hospice care, and select home health care. Medicare Part B covers particular doctors’ visits and services, outpatient care, medical supplies, and preventive services. Medicare Part D is a prescription drug additive applicable to Original Medicare, some Medicare private-fee-for-service plans, select Medicare cost plans, and Medicare medical savings account plans.
Medicare Part C
The remaining part of Medicare is Part C, which is also known as the Medicare Advantage Plan. This Medicare plan is a bundled alternative to Original Medicare. This composite of Parts A, B and generally D, are offered through private insurance companies and approved by Medicare. The Medicare Advantage Plan presents numerous key features that must be acknowledged prior to enrollment. Individuals seeking to enroll in the Medicare Advantage Plan, Part C, must grasp the requirements for qualifying for Medicare Part C, the procedure for applying for Medicare Part C, comprehension of what Medicare Part C covers, the procedures associated with enrollment for Medicare Part C and the cost of Medicare Part C.
Qualifying for Medicare Part C
The Medicare Advantage Plan is entirely optional, and carries no penalty for non-enrollment. In order to be eligible for Medicare Part C, the individual must already be enrolled in Medicare Part A and Medicare Part B. Those individuals must also reside in the area of the desired Medicare Advantage Plan. Medicare Advantage Plans generally cover more than Original Medicare and consequently, enrolled individuals will not be required to purchase a Medicare Supplement Plan, also known as Medigap. Regardless of the fact that an individual may be enrolled in a Medicare Advantage Plan, those individuals would still be required to continue paying the premiums for Medicare Part B, which varies by different insurance companies.
Applying for Medicare Part C
Applying for and enrolling in a Medicare Advantage Plan is only accessible during the specified election periods. Once becoming eligible and ultimately enrolled in Medicare, that individual may apply for a Medicare Advantage Plan, Part C. The Initial Coverage Election Period, ICEP, is the seven-month period or duration which commences three months before the month an individual turns 65 years old, including the month they turn 65. This duration concludes three months after the month an individual turns 65 years of age.
But What if I Already Receive Social Security Disability Benefits
However, in some specific cases, individuals under the age of 65 receiving Social Security Disability benefits also qualify for Medicare. Their duration period occurs during the 25th month following their initial obtainment of Social Security benefits. Those who fall into this category may enroll in a Medicare Advantage Plan three months prior to the month of eligibility, during the month of eligibility, and 3 months after the month of eligibility. For an example, if an individual’s Medicare Parts A and B coverage commenced in June, their Medicare Advantage Plan initial coverage election period would be March through September. There are numerous Medicare Advantage plans which vary by availability and costs.
The Common Types Of Medicare Advantage Plans Are:
- Medicare Preferred Provider Organization, PPO: This is a network of doctors, hospitals, clinics and other health care providers. Individuals enrolled in this program do not have to elect a primary care physician initially to coordinate their care. Those individuals may instead see any doctor, physician or specialist who accepts Medicare assignment. However, seeing a provider outside of this PPO network may incur increased out-of-pocket costs.
- Medicare Health Maintenance Organization, HMO: This type of plan allows the enrolled individuals to elect a primary care physician who will coordinate care and refer them to any required specialist. Additionally, seeing physicians outside of that network can result in the individual paying for the full amount of any service.
- Medicare Private Fee-for-Service, PFFS: This type of plan, not Medicare, sets the payment terms for the individuals. Although some of these types of plans have network providers, the majority of them allow the enrolled individuals to visit any doctor or specialist without worrying about restrictions.
- Medicare Special Needs Plans, SNPs: These plans are specially fabricated for individuals with specific chronic diseases or other special health needs. Each one of these plans requires prescription drug coverage.
- Medicare Medical Savings Account, MSA: These plans consist of two parts. The first is a high deductible plan, where coverage does not commence until the annual deductible is met. The second is a savings account plan where Medicare deposits capital to help contribute towards the high deductible amounts.
What Does Medicare Part C Cover
Ultimately, Medicare Advantage Plans or Medicare Part C covers all of the same Part A and Part B services individuals obtain from Medicare. Enrollment in a Medicare Advantage plan essentially covers both hospital and outpatient benefits. However, rather than paying for 20% of medical services and deductibles, enrolled individuals will only pay for the plan’s premiums.
Medicare Part C Is Required to Also…
Medicare Advantage plans are required to provide all of the benefits offered by Medicare Parts A and B including hospital stays, skilled nursing and home health care in addition to associated services, with the exception of hospice care which continues to be provided by Part A. The majority of these plans also provide prescription drug coverage and supplementary benefits such as eye care, hearing care, dental care, wellness services, and nurse helplines. Furthermore, Medicare Advantages plans include all of the benefits of Medicare Part B including doctor visits, outpatient care, screenings and lab tests and associated services. These plans also have different:
- Networks of providers
- Coverage regulations
- Premiums, in addition to Part B premiums
- Cost-sharing got covered services
Enrollment For Medicare Part C
As stated, enrollment for Medicare Part C requires for the individual to be already enrolled in Medicare Parts A and B. Enrollment in Medicare Advantage plans requires for those individuals to have already been enrolled in Medicare Parts A and B, be permanent residents in the Medicare Advantage Plans service areas, with a few exceptions, must not have End-Stage Renal Disease, ESRD, prior to completing the enrollment request and or a legal representative to complete an enrollment request including all of the required information to process the enrollment.
When Can I Enroll For Medicare Advantage
Enrollment in a Medicare Advantage plan is only accessible during certain periods of the year. Enrollment opportunities may be limited since the election periods occur annually. Delaying enrollment in Original Medicare results in that individual’s Initial Coverage Election Period commencing three months prior to Medicare Part B enrollment, and only lasting for three months. For an example, if an individual is eligible to enroll in Medicare Part B in May and elects to delay their enrollment until the following June, their Initial Coverage Election Period is April to June 30th.
Annual Election Period
Additionally, those individuals eligible for Medicare Advantage Plans may enroll during the Annual Election Period, AEP. This period occurs from October 15th until December 7th of each year, often referred to as “Fall Open Enrollment Season”. Furthermore, those individuals already enrolled may disenroll from their plan and return to Original Medicare between January 1st and February 14th of each year. Lastly, there are also special election periods which allow individuals to enroll in or switch their plans without waiting for the Annual Election Periods. Although this is not a common occurrence, the situations which allow for special election periods include:
- Individuals relocating out of their plan’s service area
- Qualifying for the Low-Income Subsidy program
- Having full Medicaid coverage and Medicare
- Live in a nursing home, skilled nursing facility, or rehabilitation hospital
The Cost of Medicare Part C
Medicare Part C plans generally incur lower premiums than Medigap plans. This is a result of the beneficiaries agreeing to pay copay’s as needed. Individuals must continue to pay their Part B premiums regularly, as well as any supplemental premiums that the plan may charge. In 2018, the average Medicare Part C monthly premium is $30, although this number can significantly vary by plans. Out-of-pocket costs in a Medicare Advantage plan depend on a number of factors including:
- Whether the plan charges a monthly premium, as many plans don’t have any premiums
- Whether the plan pays for any of the beneficiaries’ monthly Medicare Part B, medical insurance, premiums
- Whether the plan incurs a yearly deductible or any supplemental deductibles
- How much an individual pays for each service or visits
- How often and the type of services an individual needs
- Whether an individual requires supplementary benefits and whether the plan charges for it
- The plan’s yearly limit or cap on an individual’s out-of-pocket costs for all medical services
Before selecting and enrolling in any healthcare program, individuals must perform extensive research, while choosing the plan that best suits their situation. Additionally, individuals must grasp the requirements for qualifying for Medicare Part C, the procedure for applying for Medicare Part C, comprehension of what does Medicare Part C cover, the procedures associated with enrolling in Medicare Part C and the cost of Medicare Part C.