What is Medicare Part C?

Medicare Part C, also known as Medicare Advantage, covers everything that Medicare Part A and Medicare Part B cover, as well as a few extras. It is provided by private companies associated with the program and, in this guide, we’ll look at everything you need to know about it and its coverage.

Who is Eligible for Medicare Part C?

You need to be enrolled in Original Medicare Part A and B0 and reside in a Medicare Advantage service area to be eligible for Medicare Advantage. For Part A eligibility, you must be either:

  • Over the age of 65 and have lived in the United States for at least 5 consecutive years
  • Be classed as disabled and have resided in the US legally for 5 consecutive years
  • Have ESRD or ALS with legal status for at least 5 years

Over 65s will automatically be added to the program on the first day of their 65th birth month, but everyone else must enroll manually.

Medicare Part C Cover for Inpatient Care

Inpatient care is anything that requires you to remain in a facility and receive care under the protection of nurses and doctors.

Most inpatient care is covered under Part A of Original Medicare and the same is true for Medicare Part C. You will be covered for an inpatient stay in a hospital and a skilled nursing facility, and you may also be covered for home health care services, if needed.

Medicare Part C Cover for Outpatient Care

Outpatient care is both preventative and curative. The patient may visit doctors and other specialists but is not required to spend a prolonged period of time in a hospital or alternative medical facility.

Outpatient care is covered by Part B of Original Medicare, and Part C provides much of the same coverage, including:

  • Visits to a primary care physician
  • Visits to a specialist
  • Emergency services in an ambulance
  • Mental health services
  • Occupational therapy and other therapy services
  • Medical equipment required for illness or disability
  • Tests and x-rays

Additional Benefits to Medicare Part C

In addition to the above, Medicare Part C covers things that are not covered by Original Medicare, including many, but not all, prescription drugs. It also covers the following:

  • Dental checkups, dentures, and x-rays
  • Vision care, including eyeglasses and contacts
  • Hearing aids and hearing tests
  • Exercises classes and other health and fitness coverage

These coverage options are provided by all plans, but the extent of the coverage differs considerably. Check the details of your plan before you agree to anything, making sure you’re getting the coverage you need at a price you can afford.

What Happens if Coverage is Denied?

If your claim is denied or you are charged more than you think you should be charged, you can make an appeal against the decision. This is known as a request for reconsideration and it must be filed within 60 days of the insurer making its decision.

You will receive a response within 30 days if the decision requests a service and 60 days if it requests a payment. If these timeframes will place your health at risk or slow down your recovery, you can request an immediate review. 

If the appeal does not end in your favor, it can be forwarded to level 2 for additional review. There are 3 stages of review after this level:

  • Level 3: If you disagree with the decision reached in level 2, you can request that the case be reviewed by the Office of Medicare Hearings and Appeals (OMHA)
  • Level 4: If you are still not satisfied, a request can be made to the Medicare Appeals Council
  • Level 5: A civil action can be filed in a Federal District Court if the amount is at least $1,670

As you can see, you don’t need to accept your insurer’s decision if you do not agree with it. If there is a basis for disagreement, the appeals process will generally side in your favor.
Should you decide to take your business elsewhere after being dissatisfied with your current insurer, you can switch to a new Medicare Part C plan during the Open Enrollment Period. This runs from October 17th to December 7th every year.