Medicare Part C

How Medicare Part C is Different from Original Medicare

One way to get Medicare coverage is through Original Medicare (Medicare Parts A and B). With Original Medicare, you:

A different way to get Medicare coverage is through a Medicare Advantage plan, also known as Medicare Part C.

With a Medicare Advantage plan, you get your Medicare benefits through a private company that has agreed to rules set out by the Medicare program. As long as they obey these rules, the companies have flexibility in what additional benefits they offer, how they organize payments, and how much the plan costs.

The amount you pay depends on your plan, but most plans in California make you pay the Part B premium and more premiums for extra benefits and Part D Prescription Drug Coverage. You may still be eligible for help paying for your premiums with a Medicare Savings Program.

Medicare Advantage vs. Original Medicare

Original Medicare

Medicare Advantage

Run by:

Federal Government

Private plans

Providers:

Anyone who participates in Medicare

May be a specific network of providers

Costs:

Based on Medicare’s rules

Based on the plan’s rules

Benefit:

Medicare Parts A and B

At least as good as Original Medicare

Additional Benefits:

Through Medigap policies

May be offered as part of the plan

Drug Coverage:

Purchase a separate Part D policy

May be offered as part of the plan

Advantages:

Flexibility

Cost and additional benefits

Services Covered

Medicare Advantage plans have to help pay for all of the services that Original Medicare covers. Often, they’ll help pay for extra services. For example, with a Medicare Advantage plan, you might get help paying for preventive check-ups, hearing exams, and other services that the Original Medicare plan doesn’t cover.

With most Medicare Advantage plans, you may not have as much flexibility as you would with Original Medicare, but the amount you pay may be lower. For example, some Medicare Advantage plans may make you use certain doctors and hospitals, or may require that you see a primary care physician before seeing a specialist.

If you enroll in a Medicare Advantage plan, all of your Medicare benefits are paid for by that plan, not by Original Medicare. You can either have Original Medicare or a Medicare Advantage plan, but not both.

Some things to think about when considering a Medicare Advantage plan:
  • Look carefully at the doctors that you will be allowed to see without paying extra costs.
  • Does the plan help pay for any specialty care that you might need directly related to your disability?
  • Are there any particular doctors or facilities that you like that are on the plan?
  • What are the alternatives?

It’s important to note that Medicare Advantage plans are not Medigap policies. You do not need to have both a Medicare Advantage plan and a Medigap policy. If you already have a Medigap policy when you sign up for a Medicare Advantage plan, you can keep it, although it won’t pay for Medicare deductibles, copayments, coinsurance, or premiums. If you drop your Medigap policy, you might not be able to get it back.

To file an appeal with a Medicare Advantage plan, see your plan’s instructions or contact the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222. The California Health Advocates website also has more information on Medicare Advantage appeals.

Specific Rules about Medicare Advantage and Prescription Drug Coverage

  • Most Medicare Advantage plans offer Prescription Drug Coverage.
  • If you sign up with a plan that offers Prescription Drug Coverage, you may have to pay a higher premium, although you may still be able to get help paying these premiums.
  • If your plan offers Prescription Drug Coverage and you don’t accept it, in most cases, you cannot sign up for a different Part D Prescription Drug Coverage plan without leaving your Medicare Advantage plan.

Signing Up

In order to get a Medicare Advantage plan, you have to have Medicare Parts A and B, live in the plan’s service area, and generally can’t have End Stage Renal Disease. There are three time periods when you can sign up for a Medicare Advantage plan:

  • You can first enroll in a Medicare Advantage plan during the 3 months before, the month of, and the 3 months after you first become eligible for Medicare.
  • You can enroll in, drop, or switch plans from October 15 to December 7 each year, with benefits beginning on January 1 of the following year.
  • You can also sign up from January 1 to March 31 of each year, but if you don’t already have a prescription plan, you can’t get a plan that offers Part D Prescription Drug Coverage.

The California Health Advocates website has more information on Medicare Advantage enrollment and on when you can switch plans. You can also call the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222 for more information.

Types of Plans

There are five different kinds of Medicare Advantage plans, all of which are offered in California (although offerings vary by county). Each Medicare Advantage plan will be different, so be sure to contact the plan for more details.

To find out which specific plans are available in your area, visit the Medicare.gov website’s Medicare Plan Finder.

The five types of Medicare Advantage plans are:

Health Maintenance Organizations (HMOs)

HMOs have a network of doctors and facilities. In general, with HMOs, you choose a primary care physician from the plan’s network. When you have a non-emergency medical issue, you see your primary care physician who then provides care or refers you to another doctor in the network. In general, you can’t see doctors outside of your network and have the plan help pay for those costs.

Some plans have what’s called a Point-of-Service option, which allows you to see out of network doctors for a higher cost. In general, if the plan offers Part D Prescription Drug Coverage, you don’t have to take it, but if you refuse, you won’t be able to get another Part D policy.

Preferred Provider Organizations (PPOs)

PPOs also have networks of doctors, but unlike HMOs, you don’t have to have a primary care physician, and you don’t need referrals to see a specialist. You can go outside the plan’s network if you are willing to pay more.

If the plan offers Part D Prescription Drug Coverage, you don’t have to take it, but if you refuse, you won’t be able to get another Part D policy.

Private Fee-for-Service

These plans have certain rules that they, rather than Medicare, make up. For example, a Private Fee-for-Service plan may only pay a certain amount of money for a specific procedure. To get medical care using a Private-Fee-for-Service plan, you would go to a Medicare-approved doctor or hospital. If they agree to the plan’s terms, the plan will help pay for those medical services.

But not every doctor or hospital will agree to the terms and they can decide on a visit-by-visit basis. So it’s important to find out if they agree to the terms before you get care.

Emergency care is covered even if the doctor or hospital doesn’t agree to the terms.

Not all Private Fee-for-Service plans offer Prescription Drug Coverage. If yours doesn’t, you can sign up for a stand-alone Part D plan. Medicare's "Your Guide to Medicare Private Fee-for-Service Plans" has more detailed information on these plans.

Medical Savings Accounts

These plans have a health plan and a savings account. The health plan has a high yearly deductible. Medicare gives the Medical Savings Account plan money each year and the plan puts some of that money into a bank account. You can use this money to pay for your health costs and when you get Medicare Part A or B services, the money you spend will count towards your high deductible. Once you meet the deductible, the plan will pay for your Medicare services.

You can’t be on Medi-Cal and have a Medical Savings Account at the same time. Medical Savings Accounts don’t offer Part D Prescription Drug Coverage, but you can sign up for a separate Part D plan. Medicare’s "Your Guide to Medicare Medical Savings Account Plans" has more information on these plans.

Special Needs Plans

These are Medicare Advantage plans that provide specialized care for specific groups. People who are eligible for both Medicare and Medi-Cal, live in institutions, or have certain specific conditions (like diabetes) may be eligible for Special Needs Plans. Read Medicare’s "Your Guide to Special Needs Plans" for more information on these plans.