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What is Medicare Part C

Many people see television ads telling them they need Medicare Part C.  In this post we answer the question; What is Medicare Part C and do you actually need it.

Medicare Advantage (Part C), gives Medicare beneficiaries an alternative coverage option to Original Medicare.  Medicare A & B provide coverage for essential health care benefits such as; doctor visits and hospitalization.  Part C (MA plans) take the place of your Medicare Part A & Part B benefits and are available through private insurance companies.  They also provide many value added benefits such as prescription coverage (Part D), dental, hearing, vision, OTC benefits and more.

More details about Part C:

All Medicare Advantage (Part C) plans are offered by private insurance companies.  MA/MAPD (Part C) carriers are regulated by CMS and must provide beneficiaries the same level of medical coverage that Original Medicare (A&B) provides.

Most Part C (MA/MAPD) plans offer a very competitive premium, many plans have a $0 premium as well as low out-of-pocket costs.  This gives people a very cost effective way to get the healthcare coverage they need.

If you opt for a MA/MAPD (Part C) plan, you should be aware of the plan’s provider network and confirm that your doctors are in-network with your selected plan.  Even if you choose a PPO plan, using an out-of-network provider can be a costly mistake.

Each year, during the AEP, you have an opportunity to either enroll in or out of your current Medicare plan.  The AEP starts on Oct. 15th and ends on Dec 7th.  If you are enrolled in a MA/MAPD, you have an extra opportunity to change your coverage options starting Jan 1 and ending March 31 each year; this is called the OEP.

Summary – Why Choose a Medicare Advantage Plan (Part C):

Part C (MA/MAPD) plans provide comprehensive coverage including additional benefits such as; dental, vision, hearing, prescriptions, OTC, rides to appointments and more. They also cover Medicare A & B charges for doctors and hospitals. Many plans include Part D, prescription drug coverage.  All you need is one card to cover your medical costs.

Because MA/MAPD plans have annual out-of-pocket maximums, beneficiaries can feel safe knowing the cost of their annual healthcare has a limit.  Plans also offer clear costs for services.  Some carriers offer coordination of care benefits which is a great way for all our providers to stay in the loop on your care needs.

There are several different plan options to suit your personal needs including; HMO, PPO, PFFS, DSNP, ISNP, etc.

A Medicare Advantage plan (Part C) is not for everyone:

It is important to consider many factors before choosing Medicare Part C coverage.  Some things to think about are; your personal healthcare needs as well as your budget. With careful research and an understanding of the plan’s features, you can make an informed decision that supports your health and well-being.

One of the most important points is to make sure our providers are in-network with the plan you choose.

Consider any medical conditions you may have an dhow often you will require medical attention.  It may be a better bet to join a Medicare Supplement and prescription drug plan depending on your personal health needs.  There are co-pays, deductibles and out-of-pocket maximums to think about with a Part C plan.

Make sure you are aware of the plans Star Ratings to be sure yo consider a good quality plan.

Remember; plans change every year.  Benefits are added and taken away.  That is why it is important to work with a knowledgeable, licensed Medicare agent to help you sort out all your plan options during the AEP or OEP enrollment periods.

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Sign up for Medicare Part D

Once you enroll in Medicare, it is very important to Sign up for Medicare Part D.  A skilled Medicare agent can make choosing the best Medicare Part D (prescription drug plan) reasonably quick and easy.  Anyone who does not have credible Part D coverage when they are eligible for Medicare is subject to a lifelong penalty.

What does Medicare Part D cover:

Medicare Part D plans are prescription drug coverage.  This coverage is available to eligible Medicare beneficiaries. Part D coverage is provided by private insurance companies that are contracted with the federal government. There are 2 ways to enroll in Part D coverage.  First, beneficiaries may enroll in a PDP, stand-alone prescription drug plan, in addition to traditional Medicare.  The second choice is to enroll in a Medicare Advantage plan, MAPD these plans include Part D coverage.

Who is eligible for Medicare Part D:

If you are enrolled in either Medicare Part A or Part B and live in the Part D plan’s service area, you are eligible to enroll in a plan.  Additionally, certain individuals with limited income and resources are eligible for “extra help”.  Extra help provides help paying for drug plan premiums, deductibles, coinsurance and other costs.  Click here to learn more about “Extra Help” and how to apply.

When can you enroll in Part D:

To avoid late enrollment penalties, timely Medicare Part D enrollment is imperative. There are two primary enrollment periods.

The IEP or Initial Enrollment Period is a 7-month period.  It starts three months before you turn 65, includes your birth month, and ends three months after your birthday. Please note; if you qualify for Medicare due to a disability, you may have different enrollment periods.

AEP or Annual Enrollment Period occurs each year from October 15th to December 7th. During the AEP, you can make changes to your existing Part D coverage, such as switching plans or adding coverage.

How to choose a Medicare Part D Plan:

This is an extremely important part of your Part D enrollment.  If you choose the wrong plan, it can be a very costly mistake.  Each plan offers different coverage options. Selecting the right Part D plan is crucial, as each plan may have different premiums, coverage options, and their own network of pharmacies. Please consider the following when making a plan choice:

Make a list of all the medications you are currently on.  You may want to add in anything that your doctor will prescribe in the following months. Be sure to include the dosage and the frequency  that you take them.  This helps to find plans that cover your medications.

An insurance agent can show you a comparison of the best plan options for your needs.  If you  do not have an agent, use the Medicare Plan Finder tool on the official Medicare website. Be aware of all costs including; premiums, deductibles, copayments, and coinsurance costs.  You need to consider the total cost of each plan option.

Look at the plan’s formulary.  This is a list of drugs covered by each plan. Double check that your medications are on the list and make a note of any restrictions on your prescriptions.

Be sure the pharmacy you use is a preferred in-network. If it is not see if there are alternative pharmacies close by that are preferred in-network so you can receive the best pricing.

Check the plan’s star ratings.  This is  system based on overall service and coverage.

How to enroll in Part D:

Once you choose the best Medicare Part D plan to meet your prescription coverage needs, you have a few ways to enroll.

1.  Online: A licensed Medicare agent may be able to enroll you using an enrollment link from their quoting engine or you can enroll by going to either Medicare.gov or the website of the carrier of the plan you selected.

Click here to view a demo of how to use Sunfire to run a quote

2.  Fill out a paper application.  If you are working with an agent, they will help you fill out the necessary paperwork and send the application in for you.  If you do not have an agent, you can submit the application using the instructions provided by the carrier.

3.  Enroll over the phone.  You can call the plan carrier or call 1-800-633-4227 (1-800-Medicare).

Beware of late enrollment penalties:

If you miss your Initial Enrollment Period or do not have creditable prescription drug coverage for over 63 days, you may wind up with a late enrollment penalty. This penalty is added to your Part D premium and remains in effect for as long as you have Part D coverage.  Please note; if you receive extra help, this penalty does not apply.

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Losing Medicaid benefits

Because of the recent Medicaid redetermination, many people are losing Medicaid benefits.

During the last 3 year period, Medicaid benefits have been automatically renewed for individuals who became eligible because of the public health emergency caused by COVID-19.  During this time, beneficiaries were not required to recertify annually for Medicaid coverage.

Because the public health emergency has ended or “unwinding” as of May 11, 2023, the requirement to recertify for Medicaid coverage is back in place.  This means there will not longer be any automatic renewal and Medicaid beneficiaries must prove the need for benefits.

In other words, beneficiaries will go through redetermination.

This process takes place each year and reviews each person’s need for health care assistance through their state government. It is important to reply to any valid communication you receive from your state’s department of Social Services or DSS.  If you fail to respond, you may lose your coverage even if you do qualify.

Each state has 1 year to begin the redetermination process starting on March 31, 2023.  All states must finish processing renewals within 14 months. In other words, beneficiaries may lose Medicaid coverage as soon as April 2023.

Millions of people will lose Medicaid coverage:

Although we do not know the exact number of people slated to lose coverage, it may be over 15 million.  For many employment is a main factor in their loss of Medicaid coverage.

Some individuals will lose coverage due to not confirming eligibility with their state’s DSS offices before the expiration of their coverage.  There also may be problems with a backlog of paperwork and a processing system that is simply overwhelmed.  This can cause delays and coverage loss.  This backlog has the potential to effect millions .  That is why it is best to be proactive and go into your Medicaid account to ensure you are still eligible and covered.

Click here to learn more about the unwinding of Medicaid’s continuous enrollment

What if I no longer qualify for Medicaid:

If you reapply for Medicaid and do not qualify, there are other low cost or even free healthcare choices available to you.  The choices depend on your personal circumstances.

1.  If either you or your spouse/partner has an employer that offers health insurance coverage, you may qualify to join during either their open enrollment period or with a special election period.
2. In the interim, if you are not yet eligible for employer based coverage, you can enroll in a short-term insurance plan while you wait to qualify.  There are several options for these types of plans.
3. You can also access healthcare through the healthcare marketplace.  In many cases, beneficiaries may qualify for a subsidy and pay a low monthly premium.   If you lose health coverage, you have a special enrollment period or SEP you can use to enroll in coverage.  To find the market place for your state go to healthcare.gov/marketplace-in-your-state.
4. College students may be able to purchase health coverage directly through a campus health plan. Students can get details from their registrar’s office.
5. If you are either 65 or older or have a qualifying disability, you may be eligible for health coverage through  Medicare.  Contact a licensed Medicare agent for help going over all your plan options.
6. Anyone who is either a veteran or an active duty service member may qualify for Tricare.  Use the following link to get more information: Tricare healthcare coverage.

It’s important to note that if you believe you qualify for Medicaid, you should reapply. We’ll discuss that next. But even if you do apply, you may need to explore some of the options above while you wait to be approved.

How do I reapply for Medicaid benefits:

If you have limited income/funds, you may be eligible to retain your Medicaid coverage.   If this is the case, Click here to for information on how to apply for Medicaid.  Contact your state DSS office for applications and guidance.