Understanding Medicare Part C Eligibility Requirements

What Is Medicare Part C? Explaining Its Features and Benefits

The part c Medicare also called Medicare Advantage plans in one of the divisions of Medicare and is available from private insurance companies. The coverage of part c Medicare extends more than what Part A and Part B offer cumulatively and hence, diminishes the requirement of a Medigap or Medicare Supplement insurance. An individual is expected to properly scan through the plans before enrolling as the coverage and costs vary from place to place. Enrollment in part c Medicare requires the client to continue paying for the part B premium. There are updated Medicare part C plans that have zero premium requirement from the member, the costs being only for prescription drugs and coinsurance. Before opting for Medicare Advantage Plans one should understand the advantages and the eligibility requirements for Medicare. The unique thing about Medicare is that it is available through private insurance companies whereas Part, Part B, and Part D are handled by the government.

The Benefits of Medicare Part C Eligibility

Medicare Advantages of Medicare Part C offers wide benefits for its eligible members. The advantages of getting enrolled in Medicare Part C are something that other schemes do not offer. Starting with customized plans with a variety of options for add-ons at an affordable price. Being a member of Medicare Part C reduces the expenditure related to co-pays by 20%. With other additional benefits, it makes Part C the choice of 30% Americans who are already enrolled with Part A and Part B. Enrollment for part c Medicare is optional.

  • It provides all of your Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage.
  • You can enjoy additional great benefits such as vision, dental, and hearing, and many include prescription drug coverage.
  • You can have access to other healthcare facilities, healthcare personnel and doctors from accredited hospitals and wellness centers.
  • It has the potential to help you save money because the excess money from this plan as out-of-pocket costs in these plans can be lower than the Original Medicare, Part A, and Part B.

Things to Consider in Choosing Part C

Studies show that the trend has changed with more members opting for updated Medicare part C as compared to Medicare Supplement programs. Though the eligibility requirements for Medicare care rigorous, people are enrolling for it because of the affordable pricing.

Original Medicare

Part A can be availed at no cost if the person has worked for 10 years and have paid social security taxes. Then comes the option of enrolling for Part B which requires the payment of a premium on a monthly basis. Enrollment with Medicare Part C replaces the existing Medicare Part A and Part B insurance plans as they are available through private insurers and the coverage is equivalent of Part A and Part B combined. Medicare Part C plans have everything covered and the member doesn’t have to worry about receiving fewer benefits compared to Part A and Part B.

  • Pricing may vary from one by plan provider to another. This is why you need to be careful and in comparing all the plans in your area.
  • The cost may also vary according to the services you use and the type of plan you are about to purchase.
  • Talk to the health insurance plan directly or with a licensed insurance agent or broker.
  • You can disenroll from this plan during a Medicare Advantage Disenrollment Period. This runs from January 1 through February 14. During this period, you have the liberty to terminate your Medicare Advantage plan and return to the Original Medicare coverage.

What Does Part C Plan Cover? 

The following benefits are among the great additions that eligible individuals and members can enjoy in Medicare Part C.

  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Private Fee-for-Service (PFFS)
  • Special Needs Plans (SNPs)
  • HMO Point-of-Service (HMOPOS)
  • Medical Savings Account (MSA)

Eligibility for Medicare Part C 

  • Live within the service area of the plan you want to join in.
  • If you are currently enrolled in Original Medicare, Part A, and Part B, coverage.
  • If you do not have end-stage renal diseases also known as permanent kidney failure that required dialysis or kidney transplants. On the other hand, there are few exceptions to this provision.

For an in-depth understanding of the eligibility requirements for Medicare part C, one should be well informed about the four broad components of Medicare Insurance Scheme:

  • Part A provides coverage of hospital expenditures and has a deductible.
  • Part B provides outpatient coverage.
  •  Part C also called Medicare Advantage provides comprehensive coverage and available through private insurance companies.
  • Part D provides coverage for prescription drugs.

When To Enroll 

Along with the requirements for part c, there is a strict window during which one can apply for Medicare Advantage Plans or change an existing Medicare Part C plan. The window is called the Annual Enrollment Period or AEP. For the current year, the AEP window is from 15th October to 7th December. For members enrolled in a Medicare Supplement program and want to enroll for the advantage plans after meeting the requirements for part c, are required to follow the same timeline strictly. The eligibility requirements for part c depend on a lot of factors. According to the updated Medicare part C, one can enroll for part C after attaining the age of 65. The Initial Enrollment Period (IEP) as they call it, starts three months prior to becoming 65 years old and the period ends after three months of becoming 65.

Private Insurance

Many claims that understanding Medicare Part C programs can sometimes become confusing. A private insurance company can suggest health plans for qualified members. A short brief of the programs offered are as follows:

  • The first basic scheme is the Health Maintenance Organization Plan (HMO) which allows to avail cashless facilities from a list of hospitals that are covered in the plan.
  • The next plan called Preferred Provider Organization Plan (PPO) allows the member to visit doctors and hospitals not covered in the scheme.
  • With the Private Fee-for-Service Plan (PFFS), a member can visit literally any clinic or hospital and avail their services as long as the medical institution accepts payment from the insurance scheme.
  • A Special Needs Plan (SNP) is for people suffering from chronic diseases or living in nursing homes. It is meant for people who need special care.
  • The HMO Point-of-Service Plan (HMO POS) is identical to the HMO plan with a minor difference in the coverage which allows the members to get treatment from medical institutions that are outside the coverage but leads to higher co-payment.
  • Lastly, there is the Medical Savings Account Plan (MSA) which provides a high deductible and simultaneously deposits money on behalf of the member into a savings bank account. The savings accumulated can be utilized in the form of payments made against medical expenditure throughout the year.

Some additional criteria that need to be met for smooth enrollment into Part C Medicare program are as follows:

  • The first and most basic requirement is to possess citizenship of the U.S. or to be a permanent resident residing legally.
  • If the individual has not contributed to Social Security payments during their days of employment, it is a must to have paid at least paid for Medicare payroll.

Image result for medicare part c illustrationThe Restrictions

There are a few restrictions that bind to the Medicare Advantage plans. For example, An individual suffering end-stage renal disease (ESRD) cannot enroll for any of the Medicare part C plans unless the person had an existing similar plan before the developing of the illness. Though Medicare Part C provides the comprehensive package that covers the expenditures of basic as well as complex medical situations inclusive of the hospital charges, there might arise certain situations when a change in the current plan is required.

  • The most probable situation is normally the assigned doctor not being on the plan anymore as doctors keeping moving from one health plan to another. When the doctor required is not available anymore, a change in Medicare Advantage Plan should be availed in the upcoming enrollment period.
  • The second case being the unavailability of critical medicines is a good enough sign for the individual to change the existing Part C plan.
  • Though Medicare Advantage Plans are known for their affordable costs, the premium cost can go up and may not be feasible for members to pay the increased premium thus calls for a change in plan that suits the budget.

A simple comparison between Medicare Part C and Medicare Part D can be done to see how they are related to each other. Medicare Part D provides coverage for prescription drugs and requirement for availing the coverage is by enrolling for a Part D plan or a different Medical Advantage plan that also has provision for Part D coverage.

Enrollment Penalty 

Another thing to be kept in mind is avoiding the late enrollment penalty. Individuals who are on the verge of turning 65 should apply for enrollment in the Initial Enrollment Period (IEP) which lasts for six months in order to avoid paying penalty for the late enrollment. Enrolling for the Medicare Advantage plans after the expiry of the Initial Enrollment Period without any credible coverage will attract a late fee. It is mandatory to include the date in the enrollment form without which one may be levied charges which can be totally avoided.

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