Medicare Part C is often referred to as Medicare Advantage. This is a private health insurance plan that replaces both Medicare Part A(Original medicare) and Medicare Part B. This will basically take the place of Medicare Parts A and B.
Medicare Part C / Medicare Advantage is Government Regulated.
Medicare Part C Coverage is regulated by Government. To provide Medicare Part C Coverage a company must provide the minimum coverage received under Medicare Part A and Part B and provide for some of the gaps found in Medicare Part A and Part B coverage. Participants that enroll in Medicare Advantage plans do not need additional insurance to cover items not covered under Part A and Part B of Medicare.
Why Choose Medicare Part C / Medicare Advantage
The major reason for going with a Medicare Advantage (Part C) plan is Medicare Part C covers many items not covered under Medicare Part A and B, and the out-of-pocket expenses of a Medicare Advantage plan are usually lower than the combined expenses of Medicare Part A, Part B and a Medicare Supplemental insurance plan which covers the ‘gaps’ in Part A and Part B. Medicare Supplemental is also called Medigap for this reason.
Who is eligible for Medicare Advantage / Part C Coverage?
Any Medicare Part A and Part B qualified individual may opt to go with a Medicare Part C plan instead. In order to signup for Medicare Advantage you have to live in an area where Medicare Advantage is offered. You also have to be in an enrollment period to signup for Medicare Part C (Medicare Advantage).
Two Types of Medicare Part C Coverage Plans:
#1: Managed Care Plan
Medicare enrollees can choose from many different managed care plans. Managed plans basically provide services to members via their network of providers. HMO’s(health maintenance organizations) feature the least expensive and most common plans, but are also the most restrictive in who you can see in and out of network. PPO’s (preferred provider organizations) is another type of managed plan, as well as the point of service options that some HMO’s have which is essentially a variation to the traditional HMO.
Some common restrictions of HMO’s include:
- Medicare Part C Services can only be provided by physicians, hospitals, and healthcare facilities that are listed in the HMO’s network of providers.
- In an HMO Specialist care cannot be paid for under Medicare Part C unless the patient receives a referral from an HMO plan primary care physician.
- HMO’s have special limitations under Medicare Part C where certain services and procedures must be approved in advance before being carried out.
- With an HMO Patient appeal rights are limited with regards to what services the plan will or will not cover.
With POS (point of service) and PPO (preferred provider organization) plans members can see any provider outside the plan network. Members can also see specialists without getting a referral from their primary care physician, however the down side is that these plans pay less of the overall costs of the total bill. They are also less common than the HMO option under Medicare Part C.
#2 Private Fee-For-Service Plans :
Private Fee-for-service plans are completely different than managed care plans. PFFS plans do not possess the limitations of having to stay within a network, but allows a fee to be paid so that you can visit any provider you desire. The only major restriction is that not all providers accept PFFS plan members . Medicare Part C fee-for-service plans does not restrict a participant’s choices of doctors, or hospitals to a specific list like managed care plans, simply visit a doctor or provider that participates in Medicare and your services should be covered. Of course it’s always a good idea to discuss the billing with the specific provider before-hand to make sure that they accept your specific PFFS plan.
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