Part C

Part C, Medicare Advantage (MA) Plans

                                                                                                                                                                                                                                                                                                                                                                                                          Replaces Parts A & B of Medicare. You must still pay the Part B Premium. These are generally set up as HMOs or PPOs. They also have Private Fee for Service Plans (PFFS).  The plans are different than Medicare Supplements as there are co-pays for the different services provided. The premiums are much lower and can be as low as zero.

                                                                                                                                                                                                                                                                                                                                                                                                          When determining the best Medicare Advantage Plan, it is critical to be certain that your doctors accept the plan prior to enrolling in that plan.


MAPD Plans

 These are Medicare Advantage plans that include drug coverage.

These plans offer prescription drug coverage, typically with very low co-pays

There may be limits on the amount of prescription drugs that are covered. Be sure to check the formulary book for any plan you are presenting for co-pays or limits.

Part D, Prescription or PDP Plans

             When a Medicare beneficiary selects a Medicare Supplement or an MA that does not include drug coverage, then that beneficiary needs a PDP plan.

            There are penalties to beneficiaries for not obtaining drug coverage when they become eligible for it, unless they have credible coverage actuarially equivalent to Medicare Part D.

            Always check the current prescriptions to determine the best plan.  In some instances, assisting with formulary exception requests, or requesting aid from the drug manufacturer may be advisable.

            NOTE: If a Medicare beneficiary has an MA or MAPD plan in place, enrolling them in a stand-alone PDP plan will cause disenrollment from the prior plan. Be certain before moving forward with enrollment!

            Part D plans must cover at least the Part D standard benefit or its actuarial equivalent.

            For 2013, the standard benefit requires the beneficiary to pay:

            $325 deductible

            25% of prescription drug costs between $325 and $2,970 = $661.25

            Part of the costs in the “Coverage Gap” – After total spending on drugs by the beneficiary and the plan reaches $2,970 the beneficiary pays for 79% of generic drug costs and 50% of brand name drug costs.

            Drug manufacturers provide a 50% discount on brand name drug costs.

              A new law enacted in 2010 eliminates the coverage gap by 2020 by reducing the amount beneficiaries pay while in the coverage gap by a small percentage each year until 2020 when they will be responsible for only 25% of brand and generic drug costs.

            Catastrophic coverage: Once beneficiary expenditures (including drug manufacturer discounts) reach a total of $4,750, the beneficiary is through the coverage gap and reaches catastrophic coverage. On any future prescriptions the beneficiary pays either a co-pay of $2.65 for generic drugs or $6.60 for brand name drugs or a co-insurance of 5%, whichever is greater.


Enrollment Periods

 Beneficiaries may only enroll in or change plans at certain fixed times each year or under certain limited special circumstances.

 Enrollment periods are:

            MA Initial Coverage Election Period (ICEP)

            Part D Initial Enrollment Period (IEP)

            MA and Part D Annual Election Period (AEP)

            MA 45-Day Disenrollment Period (MADP)

            MA and Part D Special Enrollment Periods (SEP)

            Note: The Affordable Care Act eliminated the Open Enrollment Period that occurred each year from January 1 – March 31 and created the MA Disenrollment Period that takes place January 1 – February 14. This change is effective beginning in 2011.


Enrollment Period MA Options PDP Options
MA Initial Coverage Election Period (ICEP) / Part D Initial Enrollment Period (IEP) Enroll Enroll
Annual Election Period (AEP) Enroll, Disenroll, Change Plans Enroll, Disenroll, Change Plans
MA Disenrollment Period (MADP) Disenroll from an MA or MA-PD plan and return to Original Medicare After disenrolling from an MA or MA-PD plan, may enroll in a PDP
Special Election Period (SEP) Most permit enrollment, disenrollment and plan changes, however some are limited.  Refer to CMS guidance. Most permit enrollment, disenrollment and plan changes, however some are limited.  Refer to CMS guidance.


 MA Initial Coverage Election Period (ICEP)

The MA ICEP and the Part D IEP occur together as one period when a newly Medicare eligible individual has enrolled in BOTH Part A and Part B at first eligibility.

            Who is eligible for the MA ICEP?

            The ICEP is available to individuals who are newly eligible for Medicare Advantage (MA).

            When does the MA ICEP take place?

The ICEP begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends on the later of the last day of the month preceding entitlement to both Part A and Part B, or the last day of the third month after the month in which an individual meets the eligibility requirements for Part B.

            What can individuals do during the MA ICEP?

            During the ICEP, an eligible individual may enroll in an MA plan – or an MA-PD plan if the individual is eligible for Part A and enrolled in Part B.

            The individual can make one enrollment choice under the ICEP.

            Once enrollment is effective, the ICEP is used.


Special Enrollment Periods (SEP)

            Who is eligible for an SEP?

            Part D eligible beneficiaries and those enrolled in an MA plan who experience certain qualifying events are allowed an SEP.

            When does the SEP take place?

            Timeframes for SEPs vary, however, most begin on the first day of the month in which the qualifying event occurs and last for a total of three months. The SEP ends when the individual utilizes their SEP to make an allowed change, or the time period expires, whichever comes first. Where appropriate, SEPs allowing changes to MA coverage are coordinated with those allowing changes in Part D coverage.

            Some (but not all) situations resulting in an SEP include:

            Change in residence

            Involuntary loss of creditable drug coverage

            Exceptional conditions such as

            Gaining or losing Medicaid eligibility

            Gaining or losing the Part D low-income subsidy

            Changing employer/union group health plan coverage

            Enrollment based on incorrect or misleading information

            New for 2012 – 5-Star Rated MA Carriers may accept a new enrollee at any time during the Plan Year