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Medicare Part C

Medicare Advantage Private Health Plans (private plans give consumers alternate route to benefits)

Since 1997, Medicare enrollees have had the option of going beyond their Original Medicare coverage by enrolling in Medicare Advantage. And according to the Centers for Medicare & Medicaid Services, as of August 2010, approximately 1.6 million Americans have enrolled in the Part C plans.

The Balanced Budget Act signed into law by President Bill Clinton in 1997 gave Medicare enrollees the option of receiving their health care benefits through private insurance plans. Previously, the only plan available was Original Medicare.

Medicare Advantage Benefits

With Medicare Advantage plans, the essential Medicare Part A and Part B benefits – except hospice services – are automatically covered. Advantage plans also cover urgent and emergency care services, and in many cases, the private plans cover vision, hearing, health and wellness programs and dental coverage.

Insurance companies offer five different approaches to Medicare Advantage plans: an HMO (health maintenance organization), a PPO (preferred provider organization), a PFFS (Private Fee-For-Service), a MSA (medical savings account), or an SNP (special needs plan).

You need to choose your own primary care doctor with an SNP and HMO but not with an MSA, a PPO or a PFFS. In most instances prescription drug coverage is included with the exception of the MSA plan. HMOs and SNPs are the only plans that require a referral prior to seeing a specialist; and the HMO plan is the only plan in which you must receive care from doctors in that network.

What do Advantage Plans cost?

Even though Advantage enrollees have rights and protections under Medicare guidelines, the services offered and the fees charged by private insurers vary widely. A thorough understanding of how these plans work is key to successful management of your personal health.

Some Advantage plans charge monthly premiums in addition to the Part B premium. Others limit how much enrollees must pay out-of-pocket annually. Some Advantage plans have deductibles, others do not.

Co payments for doctor's visits differ dramatically, as do the actual health care services and how often enrollees receive those services. Pay close attention to the details is called for when assessing these plans.

Who is eligible to join Advantage Plans?

If you are 65, live in the designated service area of the specific plan, and already have Part A and Part B, you may join a Medicare Advantage plan. If you have union or employer-sponsored insurance, you may be able to add an Advantage plan, but be forewarned that in some cases you may lose your employer or union coverage when you enroll in an Advantage plan.

You should know that if you enroll in a Medicare Advantage Plan, you will not need to purchase Medigap coverage (and you will not be able to buy the coverage). If you already have Medigap coverage, you can keep the coverage, it won't pay for Medicare Advantage plan expenses, such as co payments.

Individuals with End-Stage Renal Disease (ESRD) are generally not eligible for Advantage plans – unless they are already in a Medicare Advantage Plan when they are diagnosed with ESRD.