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What is Medicare Advantage?

As we get older, we will spend more on our healthcare, it’s unavoidable. But luckily, it’s possible to find a Medicare insurance plan to fit your lifestyle. It’s even easy if you know who to go to. (Hint: It’s Healthpilot, you should come to us. We make it easy.)

Once you are on that search, you may notice that finding the right Medicare plan can also be a) confusing and b) dull as dishwater. Unless you are a total nerd about it all, like we are at Healthpilot. How shall we put it? We want to help you understand the different parts of Medicare and choose the best Medicare plan to fit your needs, we aim to go where “no one has gone before.”

Keep reading our guide to Medicare Advantage (also called Medicare Part C) from some Healthpilot experts who actually love this stuff.

While Medicare Parts A and B are considered Original Medicare, Medicare Part C is known as Medicare Advantage, a.k.a MA plans. The “advantage” is that Medicare Part C provides coverage through Medicare-approved private insurance companies, becoming your principal source of health coverage, and includes the same benefits as Medicare Part A and Part B, with additional perks. If Medicare Part C covers the same stuff as Original Medicare, why get a Medicare Part C plan? Because you will likely have lower out of pocket costs for these covered services. Plus, Medicare Part C offers an array of plans that can include coverage for additional benefits. There are several different Medicare Part C plan types available, costs can vary from plan to plan.

Types of Medicare Advantage/Part C

Just when you thought you knew the Medicare Alphabet and what to expect, Medicare Part C proves to be quite different and has a variety of plan types, much like private insurance…because it is private insurance. Medicare Advantage plan types may include but are not limited to the following:

Health Maintenance Organization (HMO) – HMO plans offer care from a network of medical health care providers for a set fee per service. There are a few exceptions to keep in mind, such as emergency care, out-of-area urgent care and temporary out-of-area dialysis.

Preferred Provider Organization (PPO) – Similar to an HMO, a PPO also has a network of providers that have agreed to a set fee per service; however, you are welcome to see an out-of-network provider. A PPO plan doesn’t require you to have a primary care physician (PCP), and you typically aren’t required to obtain a referral if you would like to see a specialist. This flexibility does come at a higher cost if you decide to go outside of the network, such as paying more for premiums and copays.

Health Maintenance Organization Point of Service (HMO POS) – An HMO POS is a bit of a hybrid between an HMO and a PPO. You will have to designate a PCP, but like a PPO, you may go outside the network for a higher copayment or coinsurance.

Private Fees for Service (PFFS) – PFFS plans are offered on a fee-for-service basis and do not restrict beneficiaries’ choice among providers, if the provider agrees to treat you. The plan determines how to pay the providers for services you use and how much you may owe when you get that care.

Medicare Advantage Special Needs Plans (SNP) – Special Needs Plans provide coverage for special health care or financial needs. Prescription drug coverage is included in all SNPs, but the plans’ accessibility will vary depending on where you live. Special Needs Plans come in four different variations.

  • For persons who are both Medicare and Medicaid eligible, there are dual special needs plans (D-SNPs)
  • C-SNPs (Chronic Special Needs Plans) are for those with certain severe or incapacitating chronic diseases
  • Plans are available for institutionalized individuals with special needs (I-SNPs) who reside in skilled nursing facilities for 90 days or longer
  • Individuals who reside in an assisted living facility under contract and require care comparable to that provided in a skilled nursing facility who can remain at home may be eligible for Institutional-Equivalent Special Needs Plans (IE-SNPs)

More Parts of Medicare

In order to provide greater health and financial security to people who were historically underrepresented in the traditional insurance market, the U.S. federal government established Medicare as a national health insurance program. Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). To make things simpler, the Medicare program has been divided into four main parts – A, B, C, and D.

Find out more about each of the parts of Medicare:

Medicare Part A
Medicare Part B
Medicare Advantage (Part C)
Prescription Drug Plans (Part D)
Medigap (Medicare Supplement Insurance)

Making sense of this Medicare Alphabet soup can be confusing.

To learn more about the Medicare Alphabet, visit the Healthpilot Medicare Basics Page.

Medicare Basics Page

Who is eligible for Medicare C?

Medicare Advantage Eligibility Rules

In general, to be eligible for Medicare Part C, you must fulfil both of the following requirements:

  1. Already signed up for Original Medicare (Medicare Parts A and B)
  2. Live in a service area where private insurance companies offer a Medicare Advantage/Medicare Part C plan

It is also important to keep in mind that Part C coverage is not offered automatically. You must actively enroll in a Medicare Advantage plan. These plans are sold by private insurance companies, and just like any other insurance product, the enrollment process is similar to buying any health insurance policy.

Original Medicare Eligibility

Since you have to be enrolled in Original Medicare first in order to qualify for Medicare Part C, we thought we would quickly include the basics of Medicare Part A and B eligibility.

If you receive Social Security benefits, you will be auto enrolled into both Medicare Parts A and B when you turn 65. On the other hand, if you aren’t yet receiving Social Security benefits, you’ll need to sign up for Medicare on your own.

When can I enroll in Original Medicare?

With your Initial Enrollment Period (IEP), everything begins. From three months prior to becoming 65, through your birthday month, to three months after the month you turn 65, you have a seven-month opportunity to join Medicare Parts A and B.

It is also possible to qualify for Medicare Part A and Part B before you are 65 if:

  • You have a qualifying medical condition
  • A doctor has diagnosed you with a condition that qualifies as a disability that prevents you from working

If you qualify for Medicare before you are 65, your IEP will start three months before your first month of eligibility and last for seven months.

This part’s important: You may be subject to fines in the form of higher premiums if you choose not to enroll in Medicare Parts A, B, or D when you become initially eligible.

Initial Enrollment Period for Medicare Advantage


How do I get in touch with Social Security?

While it is Medicare that covers you, you have to sign up for it through Social Security Administration (SSA). This is because the SSA manages some eligibility for Medicare, such as if you’ve paid Medicare taxes long enough to get Part A for free, a.k.a. Premium-Free Part A. (They also handle applications to join Medicare Part B.)

Signing up is easy. You can do it online at Social Security. It’s the easiest and quickest way to sign up and get help if you need it. Or if you prefer the phone, just call 1-800-772-1213 to talk to Social Security. (TTY: 1-800-325-0778).

If you or your spouse worked for a railroad, call the Railroad Retirement Board at 1-877-772-5772. (TTY: 312-751-4701)

Curious when your Original Medicare coverage actually starts? We thought this visual aid could help:

Medicare coverage start date guide

Piece of cake, right? Because the window above for the Initial Enrollment Period (IEP) can come and go pretty quickly, you definitely don’t want to be fashionably late for this event. Mark your calendars and set an alarm on your phone.

Medicare Part C Enrollment

The Initial Coverage Election Period (ICEP)

The Initial Coverage Election Period (ICEP) is when the majority of those newly eligible for Medicare who are interested in a Medicare Advantage plan make their decision to sign up for Medicare Part C. This election period is the same timeframe as the Initial Enrollment Period, as described above, if you get Medicare Parts A and B when you are first eligible. (See above graphic).

If you do not enroll in a Medicare Advantage plan during your ICEP, you may have to wait for the fall Medicare Open Enrollment Period, a.k.a Annual Enrollment Period (AEP) or go through the process of qualifying for a Special Enrollment Period (SEP).

If you chose to delay your enrollment in Medicare Part B, you will have an ICEP to enroll in a Medicare Advantage plan once you get Medicare Part B. The important thing to note here is, the eligibility period is only 3 months prior to the Part B effective date (not a full 7 months as a newly eligible individual).

Initial Coverage Election Period for Medicare Advantage

Medicare Annual Enrollment Period (AEP)

AEP or Medicare’s Annual Enrollment Period is the official time when everyone who is eligible for Medicare can enroll in a new Medicare plan(s). That’s why it’s so important to have all your ducks in a row when it comes to knowing your eligibility and being prepared for enrollment. October 15 through December 7 is another guaranteed opportunity during the year that you have to assess your own Medicare eligibility, evaluate plans and insurance carriers, and ultimately choose, hopefully, the best Medicare plan for you. There is, of course, a better way.

Let Healthpilot do all the work. In minutes, you will be able to figure out your eligibility, see our best Medicare plan recommendation for your needs, and enroll in your Medicare plan in minutes…not months.

See your recommended plan

What does Medicare Part C cover?

We know. So much information, right? But good for you for sticking it out…maybe you secretly love Medicare coverage as much as we do.

Now onto the best part: what does Medicare Advantage cover anyway?First things first, Medicare Part C coverage must include the same basic services provided by the U.S. government under Medicare Part A and Medicare Part B, also known collectively as Original Medicare. A Medicare Advantage plan typically offers hospital coverage, medical insurance coverage, and some additional coverages. You might also be covered for the following, depending on the type of plan that you select:

Prescription drug coverage. Prescription drug coverage is a feature of all Medicare Advantage Prescription Drug (MAPD) plans, even though it is not covered by Original Medicare. If you have other creditable drug coverage, there are Medicare Advantage (MA Only) plans without drug coverage. If you’re solely looking for standalone prescription drug coverage, read up on Medicare Part D plans.

What does Medicare Part C not cover?

Once a Medicare Advantage plan satisfies its requirement to provide coverage that is equal to what you could get from Original Medicare, it’s then up to the private insurance company to determine what additional services may be covered.

Medicare Part C may or may not cover prescription drugs, depending on the plan you choose. This can be a common oversight, but if this is the case for you, you will want to make sure to secure alternate prescription drug coverage. It is important to know that if you have your Part C coverage through an HMO or PPO plan, a separate Medicare Part D prescription drug plan will not be available.

What to do when something isn’t covered

If you need a service that is not covered by your plan, you can request a prior authorization. Prior authorization (PA) requests are applicable to pre-service requests only. So in other words, if the service is not covered (as communicated in a Summary of Benefits or Evidence of Coverage) and you haven’t gotten it yet, you may request prior authorization.

These are common, so don’t worry if you find this is your first option. You can also file an appeal for a medical service, item, or prescription medication cost that your doctor believes you should have or even that you already possess. You can even appeal to pay less than what was initially billed to you.

What is the cost for Medicare Part C?

Medicare Part C deductibles

Depending on the Medicare Part C plan you select, your expected costs may change because there are numerous charges involved. In addition to the Part B premium that you’ll continue to pay, a Medicare Advantage plan may have its own monthly premium and annual deductible. Because it can be a bit confusing to read about, let’s make it a bit more digestible, shall we?

Medicare Advantage (Part C) Spend at a glance

The main factors that affect how much a Medicare Advantage plan may cost include but is not limited to: the monthly plan premiums, annual deductibles, copayments, coinsurances, frequency and location of service requests, types of services required, and Medicaid eligibility.

Unless you just wanted us here at Healthpilot to handle all of that. And did we mention we do it for the rest of your life? Yes, we do.

See your recommended plan

Ready to decide if you need a Medicare Part C plan?

Stay with us, we’re in the home stretch now. These Medicare Advantage plans are optional, but a Medicare Part C plan can be a smart choice for you. If you manage any chronic conditions, see specialists and have had surgeries or inpatient hospital stays you know that the out-of-pocket costs of having original Medicare adds up. Original Medicare does not have a maximum out-of-pocket limit. A Medicare Advantage (Part C) plan can be a smart choice for you if you want the peace of mind knowing that you will have a limit on the amount you have to pay each year. Before deciding which type of Medicare plan is best for you, keep in mind that not everyone needs a Medicare Advantage plan.

Let us help you find your Medicare Advantage plan.

The Healthpilot team knows that deciphering Medicare can be difficult. Let us do the work for you. We’ll provide our best plan recommendation for you after you answer a few questions about doctors, prescriptions, pharmacies, and other benefits you want to be considered in your plan. Online enrollment is simple too. And the best news is that once you’re a Healthpilot customer, we do this for you every year for the rest of your life.

Put Healthpilot’s proprietary algorithm to work! Get an unbiased, more accurate Medicare plan recommendation. We take your health care needs and evaluate the Medicare plans to find the right plan for you. Poof! No more Medicare plan worries. Doesn’t that sound like a great idea? We thought so.

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