What Is Medicare Part C and What Does It Cover?


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Updated: June 28, 2024

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Medicare Part C, also called Medicare Advantage, is an alternative to Original Medicare. It's provided by private insurance companies that Medicare approves. Medicare Part C covers Medicare Parts A, B and sometimes D.

Medicare Part C often offers extra benefits like vision and dental care. To be eligible, you need to enroll in Medicare Parts A and B, be a US citizen or resident and meet age or disability rules. There are specific times during the year when you can enroll or make changes to your plan.

Table of Contents

What Is Medicare Part C?

Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare offered through private insurance companies that are approved by Medicare.

Part C plans bundle together different parts of Medicare, including Medicare Part A (hospital insurance), Part B (medical insurance) and usually Part D (prescription drug coverage). They often also include additional benefits not covered by Original Medicare, such as vision, dental and hearing services​.

Medicare C plans must follow Medicare's regulations but can set their own rules on accessing services. For instance, some plans might require referrals to see specialists or impose limitations on which health care providers you can see, usually requiring you to stay within the plan’s network except in emergencies.

This can affect your out-of-pocket costs and how you get medical services, which can vary from plan to plan.

Understanding Premium Costs in Medicare Part C

 

Medicare Part C beneficiaries usually pay a monthly premium for Medicare Part B. In 2024, the Medicare Part B premium averages $174.70 per month for most beneficiaries but can vary depending on income. While some Part C plans require an extra premium, most don't.

Some plans even provide a "giveback" rebate, which covers part of the Part B premium for the enrollee. This means in certain areas, it's possible to have Medicare coverage through a Part C plan and pay less than the standard Part B premium each month.

On average, Medicare Advantage enrollees pay approximately $18.50 per month for their plans in 2024.


What Medicare Part C (Medicare Advantage) Covers

Medicare Part C is a comprehensive health plan that provides the following benefits:

  • Hospital Insurance or Part A: Typically provides coverage for hospital stays, care in skilled nursing facilities and certain home health services.

  • Medical Insurance or Part B: Includes services from doctors and other health providers, outpatient care, home health care, durable medical equipment and preventive services like screenings and vaccines.

  • Prescription Drug Coverage (Part D): Most Part C plans include this, providing essential medication coverage.

For some specific plan types, like Medical Savings Account (MSA) Plans or certain Private Fee-for-Service Plans that don’t include Part D, you're allowed to join a separate drug plan. On the other hand, if you're enrolled in a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plan that doesn’t include drug coverage, you cannot join a separate Medicare drug plan.

Additional benefits often included:

  • Eye Care: Yearly exams, allowances for lenses, frames, and contacts, diabetic eye exams and glaucoma screening.

  • Dental Care: Includes check-ups, cleanings, dentures and crowns

  • Hearing Care: Coverage for exams and hearing aids

  • Wellness Programs: Includes gym memberships or discounts and wellness services

  • Transportation: Assistance getting to and from medical appointments

  • Over-the-Counter Medications: Certain plans provide allowances for these items

  • Meal Delivery: Available after hospital stays for recovery support

Medicare Advantage plans also cap annual out-of-pocket expenses for services covered under Parts A and B. Once you reach this limit, you won’t pay for additional covered services, which provides significant financial protection compared to Original Medicare.

What Medicare Part C Does Not Cover

Medicare Part C covers a broad range of health care services, but there are specific exceptions. While it includes most benefits of Original Medicare, certain areas, such as hospice care and specific costs related to clinical trials, are not covered.

  • Hospice Care: Continues to be covered under Original Medicare, even if you're enrolled in a Medicare Advantage Plan

  • Services Outside of Plan Network: Except in emergencies, most plans require you to use network providers

  • Some Cosmetic Surgeries: Procedures not deemed medically necessary aren't covered

  • Certain Costs of Clinical Trials: While Original Medicare might cover these, Medicare Advantage plans may not

  • Costs for Organ Acquisition for Transplants: These plans typically do not cover acquisition costs for organs such as kidneys.

  • New Benefits Under Legislation: Temporary benefits due to new laws may not be included

In addition, deductibles, copays and co-insurance amounts can differ significantly from those under Original Medicare

Who Is Eligible for Medicare Part C

Eligibility for Medicare Part C, or Medicare Advantage, extends to individuals who are already enrolled in Medicare Parts A and B. This includes those aged 65 or older, younger people with certain disabilities and anyone with End-Stage Renal Disease (ESRD) under recent legislative changes.

1
Enrolled in Medicare Part A and Part B

You need to be enrolled in both parts of Original Medicare.

2
Residence in the Plan's Service Area

Medicare Advantage plans are regional, so you must reside in the area where the plan is offered.

3
U.S. Citizenship or Legal Residency

To be eligible for Part C, you must have U.S. citizenship or legal residency in the United States.

4
Age or Disability

Generally, eligibility begins at age 65, but younger individuals with certain disabilities may also qualify. Also, if you receive a disability pension from the Railroad Retirement Board or Social Security Disability Insurance (SSDI) for 24 months, you are eligible.

5
Pre-Existing Conditions

Individuals with pre-existing conditions are eligible to join Medicare Advantage plans.

6
End-Stage Renal Disease (ESRD)

As of 2021, individuals with ESRD are able to enroll in a wider range of Medicare Advantage plans. However, always check if your health care providers, like dialysis facilities or kidney doctors, are in the plan’s network before joining.

Different Types of Medicare Advantage (Part C) Plans

Medicare Advantage (Part C) plans are an alternative way to receive your Medicare benefits, and they come in various formats to suit different needs and preferences.

1
Health Maintenance Organization (HMO) Plans

These plans require you to see doctors and go to hospitals that are part of the plan's network. You usually need your primary care doctor to refer you if you need to see a specialist. However, for some services like yearly mammograms, you don't need a referral.

If you're joining a Health Maintenance Organization (HMO) Medicare Advantage Plan and want prescription drug coverage (Part D), you should sign up for a plan that includes it. If your HMO plan doesn't offer drug coverage, you cannot add a separate drug plan later.

2
HMO Point-of-Service (HMO-POS) Plans

These are HMO plans that may allow you to get some services out-of-network for a higher copayment or co-insurance amount. They provide a middle ground between the strict network restrictions of HMOs and the flexibility of PPOs.

3
Preferred Provider Organization (PPO) Plans

PPO plans offer more flexibility, allowing you to see providers outside the network at a higher cost. Referrals are not typically required to see a specialist, making it easier to seek care directly.

Similar to HMO Plans, you must buy a PPO plan with drug coverage as you cannot buy a separate drug plan later.

4
Private Fee-for-Service (PFFS) Plans

These plans determine how much they will pay doctors and hospitals and how much you must pay when you get care. You can see any provider that accepts the plan’s terms, but not all providers will.

Importantly, a Private Fee-for-Service (PFFS) Plan can allow "balance billing," where providers can charge you up to 15% more than what Medicare reimburses. If your plan includes balance billing, you would be responsible for paying the usual copayment or co-insurance plus the additional amount that exceeds what Medicare covers.

5
Special Needs Plans (SNP)

SNPs are specifically designed for people with certain chronic conditions, care needs or who also have Medicaid coverage. These plans often include tailored benefits, provider choices and prescription drug coverage (Part D) to better serve their members' unique health requirements.

There are three main types of SNPs: Chronic Condition SNPs for those with severe health issues like heart failure or diabetes; Institutional SNPs for residents needing long-term care in facilities; and Dual Eligible SNPs for those who qualify for both Medicare and Medicaid.

6
Medical Savings Account (MSA) Plans

These plans combine a high-deductible health plan with a medical savings account. The plan starts covering health care costs only after you meet a high annual deductible. Money is deposited into the savings account by Medicare, which you can use to pay for health care costs not covered by Medicare.

If you exhaust the funds in your MSA before reaching the deductible, you'll pay out-of-pocket for Medicare-covered services until the deductible is met. Any money left in the account at year's end rolls over to the next year, adding to the next deposit made by Medicare.

FAQ about Medicare Part C

MoneyGeek has compiled a list of frequently asked questions to help you understand the key aspects of Medicare Part C.

Is Medicare Part C Mandatory?
How Much Does Part C Medicare Cost?

About Mark Fitzpatrick


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Mark Fitzpatrick has analyzed the property and casualty insurance market for over five years, conducting original research and creating personalized content for every kind of buyer. Currently, he leads P&C insurance content production at MoneyGeek. Fitzpatrick has been quoted in several insurance-related publications, including CNBC, NBC News and Mashable.

Fitzpatrick earned a master’s degree in economics and international relations from Johns Hopkins University and a bachelor’s degree from Boston College. He is passionate about using his knowledge of economics and insurance to bring transparency around financial topics and help others feel confident in their money moves.


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