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Challenges with Medicare Part C: Understanding Your Options

I have been providing personal financial planning advice just shy of 40 years, and as a result I am a frequent speaker at financial planning conferences throughout the United States. About 10 years ago I was asked to address Medicare Part C, also known as Medicare Advantage, as part of the personal financial planning process. For those who do not know, Medicare Part C offers an alternative way to receive Medicare benefits through private insurance plans. I was castigated for my reasoned, and quite rational observations.

Well 10 years later, the financial services industry, as well as medical providers, have come to agree with me. Some hospitals, physicians and clinics are no longer accepting Medicare Part C patients. Rarely, if ever, is Medicare Part C a personal financial planning recommendation. While Medicare Part C provides comprehensive coverage and additional benefits, beneficiaries may, and do, encounter various challenges when navigating their plan options. This blog aims to shed light on common problems associated with Medicare Part C and offer guidance on how to address them effectively.

Understanding Plan Options

Medicare Part C offers a variety of plan options, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Special Needs Plans (SNPs). Choosing the right plan can be overwhelming for beneficiaries. Personal financial planners should take time to research and compare available plans, considering factors such as premiums, deductibles, copayments, provider networks, and covered benefits. Utilize resources such as the Medicare Plan Finder tool or consult with a Medicare counselor.

Provider Network Limitations

Some Medicare Advantage plans have restricted provider networks, limiting beneficiaries’ choice of healthcare providers and specialists. Personal financial planners should review the provider network of each plan before making a recommendation to ensure that the clients preferred healthcare providers are included. Consider whether your client is willing to switch providers or travel for care if necessary. Some plans may offer out-of-network coverage, albeit (always wanted to use this word) with higher costs.

Medication Coverage Changes

Medicare Part C plans may, and do change their formularies or coverage for prescription drugs from year to year, potentially affecting the client’s access to medications. As part of the personal financial planning engagement, personal financial planners should regularly review the plan’s formulary and coverage changes during the annual enrollment period. If the client’s medication is no longer covered, encourage them to discuss alternative options with their healthcare provider, or consider switching to a different plan that better meets their needs.

Cost Considerations:

While Medicare Advantage plans often have lower premiums than traditional Medicare, beneficiaries may encounter additional out-of-pocket costs such as copayments, deductibles, and coinsurance. Personal financial planners should evaluate the total cost of each plan, as well as Medicare Part(s) A, B & D, including premiums, deductibles, and anticipated healthcare expenses. Consider the client’s healthcare needs, budget, and personal financial situation when making a recommendation. Note: Some plans may offer additional ‘bells and whistles’, such as dental, vision, or fitness programs. These tchotchkes seldom make these plans worthwhile.

Appealing Coverage Denials

Increasingly as of late, Medicare Advantage plans have denied coverage for certain services or treatments, leading to disputes and appeals. Which is why a growing number of hospitals, clinics and physicians have begun not accepting Medicare Part C patients. If the client’s Medicare Part C plan denies coverage for a service or treatment, they have the right to appeal the decision. The client should follow their plan’s appeals process and provide any supporting documentation or medical evidence to support their case. If necessary, they may need to seek assistance from a Medicare counselor or legal advocate.

Medicare laws directly impact an individual’s personal financial plan. At Paraklete® Financial we work with CPA’s as part of our client’s collaborative team of advisers. The collaborative team is essential to the personal financial planning process. For more information, please visit us at