What is Medicare Part C?

Medicare is a federal health insurance program that is available to Americans that are age 65 and over, as well as to certain individuals who have qualifying disabilities, or who have end stage renal disease (ESRD).

This program was established in 1965, and is it administered by the United States federal government. The Medicare program has four key parts, which encompass coverage for hospitalization, doctors’ and medical services, and prescription drug coverage.

What Does Medicare Part C Cover?

Medicare Part C is not actually a separate Medicare benefit. This is a part of Medicare that allows private health insurers to provide Medicare benefits to enrollees on a managed care basis in an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) fashion. Therefore, Medicare enrollees can choose to obtain their Medicare benefits through Medicare Part C instead of through Medicare Parts A and B.

Medicare Part C is also referred to as Medicare Advantage. These are private insurance plans that are run through Medicare. By law, Medicare Advantage insurance plans must cover at least all of the benefits that are covered in Original Medicare (i.e., Medicare Parts A and B). These plans do not, however, have to cover all of the benefits in exactly the same way.

In addition, there is a great deal of variation in what Medicare Part C plans cover. For example, some plans may cover less of one benefit and more of another. This means that there may also be different costs, rules, and coverage restrictions. Enrollees may also get Medicare Part D, prescription drug coverage, as a part of the overall benefits package if they choose to.

There is a wide variety of Medicare Advantage plans to choose from, and plans may differ depending upon the demographic area in which you live. There is also a monthly premium that is required for this coverage.

How Much Does Medicare Part C Cost?

Unlike Medicare Part B, Medicare Advantage plans do not have one set amount of monthly premium for all enrollees. This is because there are a number of different plans – and, because these plans are offered by private insurance companies, each insurer will typically charge a different premium rate.

In addition, if you receive services from a doctor or other health care provider that is not in the HMO or PPO network, these services may not be covered or your costs could be higher than if the provider was in the network.

Medicare Advantage plans are, however, required to abide by certain Medicare rules for covered services. For example, these plans cannot charge more than Original Medicare (Medicare Parts A and B) for certain services such as dialysis, chemotherapy, and skilled nursing facility care.

Also, Medicare Advantage Plans must also provide an annual cost cap on the amount that you pay for Medicare Parts A and B services throughout the year. Although it is important to note that each Medicare Advantage plan can charge a different amount for the cap – and the cap amount can change each year.

Who Qualifies for Medicare Part C?

In order to be qualified for a Medicare Advantage plan, you must be at least 65 years old, and you must also be qualified to receive (or already be receiving) Social Security retirement or Railroad Retirement Board Benefits.

If you are under age 65, you must be qualified to receive (or already be receiving) Social Security disability or Railroad Retirement Board benefits for at least 24 months and be able to show proof of your medical condition.

In addition, in order to qualify for Medicare Part C, you must be able to confirm that you are a citizen or a permanent resident of the United States and that you live in an area that provides Medicare Advantage plans.

How Do You Apply for Medicare Part C?

There are only certain times when you can sign up for or make changes to a Medicare Advantage plan. These include:

  • When you initially become eligible for Medicare (during your Medicare initial enrollment period)
  • Under certain circumstances that will qualify you for a Medicare Special Enrollment Period, such as if you move, if you become eligible for Medicaid, you qualify for the Extra Help program, or if you are getting care in a skilled nursing home facility or long-term care hospital

In most instances, if you have end stage renal disease, you will not be eligible to apply for a Medicare Advantage plan.

In order to apply for coverage, you should contact the Medicare Advantage plan insurance carrier of your choice directly.


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