Medicare Part C is also known as the Medicare Advantage program. Medicare Advantage plans are private plans that pay instead of Medicare.
Many Medicare Advantage plans have lower premiums than Medigap plans. Members who enroll will use a network of doctors that are contracted with the plan. Each plan has its own Summary of Benefits, which includes information the copays and cost-sharing that you can expect to pay while on the plan. For example, you might spend $25 to see a primary care doctor and $50 to see a specialist. If you go into the hospital, you might spend $200 per day for a certain number of days.
Since members will often have copays for many services, each plan must have an Out-of-Pocket Maximum to protect you. Every insurance company sets their own maximum, but Medicare regulates it. Currently the highest allowable out of pocket is $6700. This means that in the worst-case scenario, your spending is capped at $6700 for Medicare Part A and B services in a calendar year. After that point, the insurance company must pay the rest.
Medicare Advantage plans also often include a built-in Part D drug plan. Some plans may have ancillary benefits as well, such as routine vision, dental, and hearing exams.
Texas Medicare Part C Eligibility
To join a Medicare Advantage plan, you must be enrolled in both Medicare Parts A and B and live in the plan’s service area. You must also be able to answer no to one health question. The question asks whether you have been diagnosed with End Stage Renal Failure (ESRD). Typically ESRD is when you are on dialysis or awaiting a kidney transplant. People with ESRD are not eligible for Medicare Advantage plans.
You must also enroll in a Medicare Advantage plan during an approved election period.
Texas Medicare Part C Enrollment
Medicare Advantage plans have limited enrollment windows for a good reason. Congress does not want people to wait to enroll in an insurance plan after they are sick. This would create instability with the insurance companies. By designating specific enrollment periods, they encourage people to enroll in a plan and use it as the proper insurance plan that it was intended to be.
Initial Enrollment Period
When turning 65, your Initial Enrollment Period is a 7 month window surrounding your 65th birthday. It begins 3 months prior to your birthday month and runs through 3 months after your birthday. You can choose any Medicare Advantage that operates in your area during this window. You will be enrolled for the rest of the calendar year.
Annual Enrollment Period
You can enroll, dis-enroll or change your Medicare Advantage plan during the fall. The Annual Enrollment Period begins on October 15th – December 7th. Changes made will become effective on January 1st. Medicare Advantage plans redefine their benefits annually. Members will receive notices by mail in September to tell them the upcoming changes to the plan for the following calendar year. The plans’ benefits, formulary, pharmacy network, provider network, premium and/or co-payments and co-insurance may change.
Since your plan’s benefits may change, you get an annual window to change your plan to something else if you don’t like the changes coming around on your current plan.
Special Election Period
Special Election Periods exist for certain circumstances. For example, if you are still working at age 65 and you later retire mid-year, you will have a Special Election Period to join a plan at that time. Another example would be if you move out of Dallas, Texas to another city where your current plan does not operate, you will lose your eligibility for your current plan. You may join a plan in your new area of residence during your Special Election Period.