Top 5 Reasons NOT to do Part C: Medicare Advantage

Medicare, a health insurance program for older folks , has different parts to help cover various health needs. One of these parts is Medicare Part C, also known as Medicare Advantage. In this article, we’ll explain what Medicare Part C is and tell you 5 reasons to avoid Part C  Medicare Advantage .

 

What’s Medicare Part C?

Medicare Part C, or Medicare Advantage, is another way to get your Medicare benefits. Instead of signing up for the regular Medicare plan (Part A and Part B) and buying separate drug coverage (Part D), you can pick a Medicare Advantage plan. These plans come from private insurance companies that Medicare approves, and they offer both Part A and Part B benefits, often with extra stuff.

How Does Medicare Advantage Work?

Think of Medicare Advantage plans like a single package deal that combines Part A (for hospitals) and Part B (for medical stuff). You still pay your Part B premium (a monthly fee), and usually, you’ll pay an extra premium for the Medicare Advantage plan.

Important Things to Know About Medicare Advantage:

1. Network-Based Care: Most Medicare Advantage plans have a group of doctors and healthcare places you can go to. You might need to choose from this group to get the best benefits. Some plans let you use out-of-network places, but it might cost more.
2. Extra Perks: Medicare Advantage plans often give you more than regular Medicare. This can include things like drug coverage (Part D), dental care, eye check-ups, hearing aids, gym memberships, and more. These extras can be pretty nice.
3. Paying for Care: How much you pay can be different from regular Medicare. There are co-pays, deductibles (what you pay before insurance helps), and a maximum amount you’d pay in a year (out-of-pocket maximum). These numbers can change, so it’s important to look at them when picking a plan.
4. Enrolling in a Plan: You can usually join or change your Medicare Advantage plan during the Annual Enrollment Period (AEP). This time happens from October 15th to December 7th each year.
5. Special Times to Join: Some people can sign up during Special Enrollment Periods (SEPs). These special times can come if you move or lose other insurance.
6. Different Types of Plans: Medicare Advantage plans have different types, like HMOs, PPOs, PFFS, and SNPs. Each type has its own rules and things it covers.

5 Reasons to Avoid Part C

1. You are restricted to a network

In short, a network in health insurance is a group of doctors and places that work with a certain insurance plan. Sticking with in-network providers is usually cheaper, while going out of network can cost more. Knowing your plan’s network and rules helps you make smart decisions about your healthcare and how much it will cost. Some insurance plans, like HMOs, ask you to pick one main doctor, called a primary care physician (PCP). You need your PCP’s permission to see specialists. This helps the insurance company keep track of costs and make sure you get the right care.

Insurance plans can change their networks sometimes. It’s important to check if your favorite doctors and places are still in the network. If not, you might need to pick a different plan or pay more to see them.

2. Prior Authorizations are required 

In health insurance, “prior authorization” is a system where you need your insurance company’s permission before getting certain medical services, treatments, or medicines covered. Your doctor has to explain to the insurance company why they believe the suggested treatment or medicine is necessary for your health. They need to give details about your health condition, what treatments you’ve tried before, and why this one is the best choice. After looking at everything, the insurance company will say “yes” or “no” to the request. If it’s a “yes,” they’ll pay for the treatment or medicine.

3. Copays and Coinsurance 

A co-pay, which is short for “copayment,” is a set amount of money you have to pay for certain healthcare services or medicines. It’s like a fixed fee, and you usually pay it when you get medical help or pick up your prescriptions.

Co-insurance, on the other hand, is a way for you and your insurance company to share the cost of covered medical services. Generally, coinsurance can be 10, 20 or even 3o%. Every plan is different.

You will pay copays or coinsurance for most services , until you have reached your yearly out of pocket limit.

4. Out of state coverage is limited 

The rules for out-of-state care can change depending on the type of Medicare Advantage plan you have. For example, HMO plans usually have stricter rules and may only cover emergencies outside your home state. PPO plans often offer more flexibility, allowing you to get care out of state at a lower cost, especially if you use in-network providers.

These plans have specific areas where they work. If you spend a lot of time in another state, like being a “snowbird” or living part-time in a different place, you should pick a plan that covers both areas.

Medicare Advantage plans will always cover emergency care anywhere in the U.S. for you. But when it comes to regular medical care outside your home state, the rules can change based on your plan type and plan details.

5. These plans change every year

Ever hear the saying , tomorrow is not promised? Well, next year is not promised with Part C plans. No one knows what Medicare Advantage Plans will look like in 5 years . These plans have one year contracts and plan benefits and coverage levels change every year. Part C plans have gotten gradually better over the last decade, but could they reverse and get worse? No one truly knows.

Conclusion

According to the Kaiser Family Foundation, more than half of Medicare beneficiaries have Part C plans. These plans help a large amount of people and this article is simply telling both sides of the story . Part C plans have many perks and certain benefits that are crucial for seniors; however there are some drawbacks to these plans and we try to tell both sides of the story at LMS.

To find out if this type of coverage is good for you, reach out to a local insurance broker or call Medicare directly to get more information on all your options

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