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Medicare Advantage (Part C)

Medicare recipients often find that Medicare's original plans do not offer all of the coverage they want or need.  With Medicare Advantage plans, Medicare beneficiaries are offered the choice to get their Medicare through private companies which include additional benefits. Parts A and B of your standard Medicare plan cover hospital care and then medical, respectively, but it is possible that for you, your medical needs require a bit more coverage than that. 

If you looked at the coverage benefits for Original Medicare and were disappointed to find dental, vision, or other needs were not included in Parts A or B, then a Medicare Advantage (Part C) plan might be precisely what the doctor ordered. 

What Do I Need in Order to Be Eligible for Medicare Advantage (Part C)?

Generally, there are no health qualifications for Medicare Advantage (Part C) because they are offered to most recipients that already have Medicare Parts A and B. To qualify for Medicare, you need only have lived as a permanent resident in your state for at least five years, be 65 years of age or older (or, if younger, you receive disability benefits, have Lou Gehrig's disease, or end-stage renal failure). 

The qualifying for Medicare Advantage (Part C) include:

  • Being enrolled Medicare Parts A and B,
  • Living in an Advantage plan's service area, 
  • Not having end-stage renal disease.  You can talk to a Medicare broker to explore your options and try to find programs that make exceptions, however. 

What Types of Medicare Advantage (Part C) Plans Are There?

Private insurance companies offer a range of different Medicare Advantage (Part C) plans to suit a variety of needs. 

These can include:

  • HMO, or Health Maintenance Organization Plans. Healthcare comes through a network of providers and hospitals, and these require a primary care physician. 
  • PPO, or Preferred Provider Organization Plans. More flexible than HMO, your costs are typically lower if you stay within your provider network, but you can go outside of the doctor network for a higher copay, and you don't need referrals or a primary care physician.
  • SNP, or Special Needs Plans. These are for people with chronic conditions, that have both Medicare and Medicaid, or that live in institutions. Usually, they are tailored to your given situation. So a recipient with a chronic condition would have a plan with benefits that are specific to their needs. 

With a Medicare Advantage plan you get all your Medicare through a private insurance company.  Therefore you have one card that you show at the doctor, hospital, and pharmacy. Although you are still enrolled in Medicare you do not show your Original Medicare card and any bills should be paid by the Medicare Advantage (Part C) card and not Medicare through the government.  

Medicare Advantage plans have to offer what Medicare has or better.  These may have a copay for various healthcare services and the plans cost sharing varies based on the plan.  Each county offers different plans.

What should you know before enrolling in a Medicare Advantage (Part C) plan?

  • Does your doctor/hospital accept this plan?  

    • As stated above Medicare Advantage plans are typically HMO or PPO and therefore the doctors and hospitals you want to utilize should be in network.

  • What is the cost sharing for healthcare and monthly premium of the plan?

    • Each plan has a monthly fee along with copays/coinsurance for healthcare services.  Make sure you shop the plans available in your area to find the plan that offers the lowest out of pocket costs for the services you may need.

  • What price are your medications covered at?

    • Medicare Advantage plans typically include prescription drug coverage and each plan categorizes the medications into tiers.  The tier your medication is in relates to the cost you have to pay for that medication. Plans can also have deductibles for medications.  Make sure your medication is covered in the plans formulary (list of medications the plan covers) and at what cost.

  • What is the star rating of the Medicare Advantage plan?

    • The Center for Medicare and Medicaid Services has a star rating system which is based on a number of categories including how members rate the plan.  Plans fall between 0 and 5 star rating with 5 star being the highest.

You may find one or all of these types of Medicare Advantage (Part C) plans in your area. Consult with an agent in New Jersey Medicare Brokers for free to narrow your options to one that's right for you. These experts are dedicated to helping Medicare recipients to navigate the sea of options available with unbiased expertise.

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