What Is Medicare Part C? Coverage, Cost & How It Works

Medicare Part C, also called Medicare Advantage, replaces Original Medicare with a private plan that adds dental, vision and drug coverage in one bundle. Most plans charge $0 beyond the $202.90 monthly Part B premium.

Written by Mark Fitzpatrick

Updated: April 22, 2026

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Key Takeaways

Medicare Part C, also called Medicare Advantage, replaces Original Medicare with a private plan bundling hospital, medical and usually drug coverage.

Medicare Advantage plans often add dental, vision, hearing and fitness benefits that Original Medicare doesn't cover at all.

Enrollees still pay the $202.90 monthly Part B premium to CMS, plus any additional premium the private insurer charges.

Every Part C plan caps in-network out-of-pocket spending, with 2026 plans averaging a $6,312 MOOP across all plan types.

What Is Medicare Part C?

Medicare Part C is an alternative to Original Medicare, not a supplement to it. When you enroll in a Part C plan, a private insurer contracted with CMS delivers your Part A and Part B benefits and most plans fold Part D drug coverage into the same package. You keep Medicare eligibility, but claims, network and cost-sharing run through the private carrier.

Part C is the legal name in federal statute. Medicare Advantage is CMS's consumer-facing brand for the same program.
Every Medicare Advantage plan must cover at least everything Original Medicare covers, per CMS.
You can't hold a Medicare Advantage plan and a Medigap policy at the same time.
Medicare Advantage sits inside the broader health insurance market, giving seniors alternatives to Medigap plus Original Medicare bundles.

Who Is Eligible for Medicare Advantage?

You qualify for Medicare Advantage once you're enrolled in both Medicare Part A and Part B and live in the plan's service area, defined at the county level. There's no health exam and insurers can't deny you based on pre-existing conditions. ESRD enrollees, previously excluded from most Medicare Advantage plans, gained full eligibility starting in 2021 under the 21st Century Cures Act.

Initial Enrollment Period (IEP)

The Initial Enrollment Period runs seven months total, from three months before your 65th birthday month through three months after. Enrolling before your birthday month means coverage starts the first of that month. Missing this window can trigger permanent Part B late-enrollment penalties that add 10% to your premium for each full 12-month period you went without coverage.

Annual Enrollment Period (AEP)

AEP runs October 15 to December 7 every year, with coverage starting January 1. During AEP, you can join, switch or drop a Medicare Advantage plan with no underwriting. This is the primary shopping window for current Medicare enrollees who want to compare plans.

Medicare Advantage Open Enrollment Period (MA-OEP)

MA-OEP runs January 1 to March 31 and applies only to people already enrolled in a Part C plan. It lets you switch to a different Medicare Advantage plan or return to Original Medicare, but you cannot use it to join Part C for the first time.

Special Enrollment Periods (SEPs)

SEPs open outside standard windows when you move out of your plan's service area, lose employer coverage, qualify for Medicaid or experience another qualifying life event. Most SEP windows last 60 days from the triggering event, per CMS.

What Medicare Part C Covers Beyond Original Medicare

Every Medicare Advantage plan covers inpatient hospital care, outpatient medical services, preventive screenings, emergency care, prescription drugs on most plans and supplemental benefits Original Medicare excludes entirely. About 89% of Medicare Advantage plans bundle Part D drug coverage as MA-PD plans, so most enrollees don't need a standalone drug plan.

Inpatient hospital and skilled nursing care

Part C plans cover inpatient stays, skilled nursing facility care after a qualifying hospital admission and hospice through Original Medicare. Cost-sharing is set by the plan, not by the Part A deductible. Some plans waive the first few days of hospital copays, others apply daily copays up to a plan-specific cap.

Outpatient medical and preventive services

Doctor visits, lab work, outpatient surgery, durable medical equipment and annual preventive screenings are covered, usually with a flat copay rather than the 20% coinsurance Original Medicare charges after the $283 annual Part B deductible. ACA-mandated preventive services are covered at $0 on all compliant plans.

Prescription drug coverage

Most Medicare Advantage plans include Part D coverage built in, so you don't enroll in a separate Part D plan. Each plan maintains its own formulary and tier structure. The Inflation Reduction Act caps annual Part D out-of-pocket spending at $2,100 in 2026, after which the plan covers 100% of covered drug costs.

Dental, vision and hearing benefits

Routine cleanings, exams and often major dental work up to a plan-set annual maximum.
Annual eye exams plus an allowance toward frames, lenses or contacts.
Hearing exams and a plan allowance toward hearing aids, which Original Medicare doesn't cover at all.

Wellness and lifestyle benefits

Most Part C plans include gym membership through SilverSneakers or a similar program, transportation to medical appointments, over-the-counter product allowances and 24/7 nurse lines. Special Needs Plans layer in chronic-condition care coordination and meal delivery after hospital discharge.

What Medicare Part C Doesn't Cover

Medicare Advantage plans don't cover long-term custodial care, most care received outside the plan's network, cosmetic procedures or services Original Medicare also excludes. Coverage gaps on HMO plans are wider than on PPO plans and network restrictions are the most common source of unexpected bills for new Part C enrollees.

Long-term custodial nursing home care

Skilled nursing is covered short-term after a qualifying hospital stay, but custodial care (help with bathing, dressing, eating) in a nursing facility isn't covered by any Medicare plan, Part C included. Medicaid is the program that pays for long-term custodial care once you meet state income and asset rules.

Out-of-network care on HMO plans

Outside of emergency or urgent care, HMO Medicare Advantage plans generally pay nothing if you see a provider outside the plan's network. PPO plans do cover out-of-network providers, but at a higher cost share and under a separate, higher MOOP.

Cosmetic procedures and most overseas care

Elective cosmetic surgery, routine dental implants beyond plan limits and medical care received while traveling outside the U.S. are generally excluded. A handful of plans offer limited emergency coverage abroad as a supplemental benefit, but it's not a standard Part C requirement.

Supplemental benefits vary by plan and region. Review the plan's Evidence of Coverage and Summary of Benefits on Medicare.gov before enrolling.

The Four Plan Types Under Medicare Part C

The four Medicare Advantage plan types differ on two things that drive almost every enrollee's decision: whether you need a referral to see a specialist, and whether out-of-network care is covered at all. HMOs are the least expensive and most restrictive option. PPOs cost more but allow out-of-network visits. PFFS and SNPs serve specific enrollee profiles.


HMO	Yes	Emergency only	$0 (most plans)	Cost-focused enrollees with local providers
PPO	No	Yes, at higher cost share	$20–$60/month	Enrollees who want provider flexibility
PFFS	No	Yes, if provider accepts terms	$30–$80/month	Rural enrollees with limited network options
SNP	Yes (typically)	Limited	$0–$30/month	Enrollees with chronic conditions, dual eligibility or institutional care needs

Roughly 62% of Medicare Advantage enrollees chose HMO plans in 2025 because of the premium savings, per CMS enrollment data, but PPO enrollment has grown every year as more plans add nationwide network options. Comparing Medicare Advantage plan options side by side during Annual Enrollment can surface lower-cost alternatives in your county.

Monthly premiums represent consolidated 2026 costs for Medicare Part C and Part D coverage, based on MoneyGeek's analysis of 64,249 CMS CY2026 plan records. Median and average rates are shown separately because 60% of plans charge $0, which skews averages. Individual costs vary by location, insurer and coverage level.

How Medicare Part C Works

Medicare Advantage plans pay your providers directly instead of routing through Medicare. When you see a doctor, the plan applies its own copay, coinsurance and deductible rules, then tracks your spending against the annual in-network out-of-pocket maximum. After you hit that ceiling, the plan covers 100% of in-network covered services for the rest of the calendar year.

Below is an example of how office visit plays out on an HMO Medicare Advantage plan:

1
Confirm your primary care doctor is in network
Before booking, verify your primary care doctor is in the plan's network to avoid unexpected out-of-pocket costs.
2
Pay a flat copay at check-in
You pay a flat copay at check-in, often $0 to $20 for primary care on most HMO plans.
3
Provider bills the Part C insurer
The provider bills the Part C insurer, not Medicare, for the remaining charge.
4
Insurer applies negotiated rate
The insurer applies its negotiated rate and pays the covered portion.
5
Costs count toward your annual MOOP
The copay and any coinsurance count toward your annual in-network MOOP.

DOES YOUR PLAN TYPE CHANGE YOUR OUT-OF-POCKET RISK?

HMO Medicare Advantage plans restrict you to in-network providers except for emergencies, which means out-of-network care generally isn't covered at all. PPO plans let you see out-of-network doctors, but the out-of-network MOOP runs higher than the in-network cap. The 2026 average in-network MOOP across all plan types is $6,312, per MoneyGeek's analysis of CMS data, though plans can set the cap as high as $9,250. Check your plan's Evidence of Coverage for both numbers before enrolling.

Cost of Medicare Part C in 2026

Your Medicare Advantage cost isn't just the plan premium. Every enrollee keeps paying the $202.90 monthly Part B premium directly to CMS, and the Part C plan layers its own premium, deductible, copays and MOOP on top. Sixty percent of plans charge $0 in additional premium, but a $0 plan premium doesn't mean $0 cost of care once copays and coinsurance stack up.


Part B premium (all enrollees)	$202.90/month	Paid directly to CMS, required regardless of plan
Average Part C plan premium	$17/month	60% of plans charge $0, paid to private insurer
Average Part D premium (MA-PD)	$0 (included)	Included in most MA-PD plans
Average in-network MOOP (all plan types)	$6,312/year	Per MoneyGeek analysis of CMS CY2026 data
Average in-network MOOP (HMO)	$5,479/year	Per MoneyGeek analysis of CMS CY2026 data
Maximum in-network MOOP allowed (2026)	$9,250/year	CMS-set ceiling; individual plans vary
Maximum combined MOOP (PPO, in + out-of-network)	$13,900/year	CMS-set ceiling for 2026
Part B deductible	$283/year	Applies before coinsurance on outpatient services
IRMAA surcharge threshold (individual)	$109,000 MAGI	Per SSA, applies to Part B and Part D premiums
IRMAA surcharge threshold (couple)	$218,000 MAGI	Per SSA, applies to Part B and Part D premiums

Higher-income enrollees also pay an Income-Related Monthly Adjustment Amount (IRMAA) surcharge on both Part B and Part D premiums. IRMAA applies above $109,000 in modified adjusted gross income for individuals and $218,000 for couples in 2026, per SSA. Average Medicare Advantage premiums are lower than Medigap plus standalone Part D for most enrollees, though that math shifts if you need frequent out-of-network care.

Monthly premiums represent averages across available plans based on MoneyGeek's analysis of 64,249 CMS CY2026 Medicare Advantage plan records. MOOP costs reflect average in-network limits for 2026. Individual plan costs vary by location, insurer and coverage level.

Pros and Cons of Medicare Part C

Medicare Advantage trades lower monthly premiums and bundled extras for network restrictions and variable cost-sharing in heavy-use years. The decision usually comes down to how much you travel, how predictable you need your costs to be and whether your preferred doctors are already in the plan's network.

Benefits and Disadvantages of Medicare Part C

Pros of Medicare Advantage

Lower monthly cost than Medigap

Sixty percent of Medicare Advantage plans charge $0 in plan premium, so your only monthly Medicare cost is the $202.90 Part B premium. Medigap plus standalone Part D usually adds $150 to $450 more per month, though the exact amount varies by age, state and plan type.
Bundled dental, vision and hearing coverage

Original Medicare covers none of these benefits. Medicare Advantage plans bundle dental, vision and hearing as standard benefits, with dental maximums from $500 to $5,000 and hearing aid allowances from $500 to $2,500 depending on the carrier and plan.
An Annual Out-of-Pocket Ceiling Original Medicare Doesn't Have

Every Medicare Advantage plan caps in-network spending, with 2026 plans averaging a $6,312 MOOP across all types, per MoneyGeek's CMS analysis. Original Medicare has no out-of-pocket maximum at all.

Cons of Medicare Part C

Network restrictions limit provider choice

HMO plans pay nothing for out-of-network care outside emergencies, and PPO plans charge a higher cost share for out-of-network visits, with combined MOOPs reaching $13,900 in 2026 under CMS rules.
Referrals required on the most affordable plans

HMO and SNP Medicare Advantage plans require a primary care referral before you can see most specialists. That adds a step and a delay every time you need specialty care, which is a real friction point for enrollees with chronic conditions.
Costs can accelerate in heavy-use years

Copays and coinsurance stack with every visit, and a hospital stay can push you toward the MOOP quickly. HMO plans average a $5,479 in-network MOOP in 2026, which is still a large potential annual exposure for fixed-income enrollees.

Medicare Part C vs. Original Medicare Plus Medigap (Medicare Supplement)

Medicare Advantage and Original Medicare plus a Medigap (Medicare Supplement) policy are the two competing paths for Medicare-eligible adults. The trade-off is predictability versus flexibility: Medigap locks in nationwide access to any Medicare-accepting provider at stable costs, while Part C lowers your monthly spend and adds benefits but restricts you to the plan's network and rules.


Monthly cost beyond Part B premium	Often $0 plan premium	Typically $150–$450 more/month (varies by age, state and plan)
Provider network	Restricted to plan network (HMO) or higher cost out-of-network (PPO)	Any Medicare-accepting provider nationwide
Referrals required	Yes on HMO and SNP plans	No
Dental, vision, hearing	Included as standard benefits	Not covered, requires separate plan
Prescription drug coverage	Included in most MA-PD plans	Requires separate Part D plan
Annual out-of-pocket maximum	Yes, 2026 average $6,312 in-network	None (Medigap fills gaps but no MOOP)
Medigap availability after enrollment	Not allowed simultaneously	Available, guaranteed issue window applies
Plan availability	Varies by county	Nationwide

You can switch from Part C to Original Medicare during the Medicare Advantage Open Enrollment Period (January 1 to March 31), but most states let Medigap (Medicare Supplement) insurers underwrite or deny you outside your initial six-month guaranteed-issue window. That's the single biggest reason enrollees regret delaying a Medicare Supplement decision.

Is Medicare Advantage the Right Choice for You?

Medicare Advantage makes sense when your providers are in one local network and you want lower premiums plus extras like dental and vision. It's the wrong fit when you travel frequently, need nationwide specialist access or want cost-sharing that stays fixed year to year. Match your usage pattern to the plan type before you enroll.

When Medicare Advantage Makes Sense

You want the lowest monthly Medicare cost

Sixty percent of Medicare Advantage plans charge $0 in plan premium, meaning your only monthly Medicare obligation is the $202.90 Part B premium. The trade-off is network restriction, which is manageable if your doctors are already in network.

You need dental, vision or hearing coverage

Original Medicare covers none of these benefits and Medigap (Medicare Supplement) policies don't either. A Part C plan bundles dental, vision and hearing as standard benefits, not optional add-ons you pay extra for.

You want one plan, one card and one out-of-pocket cap

Medicare Advantage rolls hospital, medical and drug coverage into a single plan with one premium, one deductible and one MOOP. That's simpler than managing Original Medicare plus a Medigap policy plus a standalone Part D plan.

When Medicare Advantage Doesn't Make Sense

You travel frequently or live in multiple states

Medicare Advantage networks are built around your home county and HMO plans pay nothing for out-of-network care outside emergencies. Medigap plus Original Medicare covers any Medicare-accepting provider nationwide, with no network to check.

You want stable, predictable costs for high-use years

Part C copays and coinsurance accumulate with every specialist visit and hospital stay. Medigap Plan G covers nearly all Medicare cost-sharing gaps for a flat monthly premium, with no per-visit surprise billing.

Medicare Part C: Bottom Line

Medicare Part C bundles hospital, medical and usually drug coverage into one private plan that adds dental, vision and hearing benefits Original Medicare skips. You'll always pay the $202.90 monthly Part B premium and 60% of plans charge nothing on top. Choose Medicare Advantage for lower costs and extras, choose Medigap for nationwide flexibility.

Understanding Medicare Advantage: FAQ

The most frequently asked questions about Medicare Part C and how it works are answered below:

Is Medicare Part C the same as Medicare Advantage?

Medicare Part C and Medicare Advantage refer to the exact same program. Congress created Part C in 1997 and CMS rebranded it Medicare Advantage in 2003. Both terms appear in plan documents and insurers use them interchangeably.

Do I still pay the Part B premium if I enroll in Part C?

Every Medicare Advantage enrollee keeps paying the $202.90 monthly Part B premium directly to CMS. Any plan premium the insurer charges comes on top of that, though 60% of 2026 plans charge $0 additionally.

Can I go back to Original Medicare after joining a Medicare Advantage plan?

The Medicare Advantage Open Enrollment Period (January 1 to March 31) lets you drop Part C and return to Original Medicare. Adding a Medigap policy afterward may require medical underwriting outside your guaranteed-issue window.

Does every Medicare Part C plan include prescription drug coverage?

Most Medicare Advantage plans, called MA-PD plans, include Part D coverage built in. A small share don't include drug coverage and enrollees on those plans can't add a standalone Part D plan separately.

Are dental and vision benefits the same across all Medicare Advantage plans?

Dental, vision and hearing benefits vary plan by plan and county by county. Annual dental maximums range from $500 to $5,000 and hearing aid allowances range from $500 to $2,500 depending on the carrier.

Can a Medicare Advantage plan drop me if I get seriously ill?

A Part C insurer can't disenroll you mid-year based on your health status. Insurers can exit a service area or discontinue a specific plan at year-end, which triggers a Special Enrollment Period to switch.

About Mark Fitzpatrick

Mark Fitzpatrick, a Licensed Property and Casualty (P&C) Insurance Producer in Connecticut, is MoneyGeek's resident insurance expert. He has analyzed the insurance market for almost a decade, first with LendingTree and now with MoneyGeek, conducting original research on hundreds of insurance companies and millions of insurance rates for insurance shoppers.

He writes about economics and insurance on MoneyGeek, breaking down complex topics so people can have confidence in their purchase. Like all MoneyGeek analysts, Mark collects and analyzes independent cost and consumer experience data on insurance companies to provide objective recommendations in our content that are independent of any of MoneyGeek's insurance company partnerships.

His insights on products ranging from car, home and renters insurance to health and life insurance have been featured in The Washington Post, The New York Times and NPR, among others.

Mark holds a master’s degree in economics and international relations from Johns Hopkins University and a bachelor’s degree from Boston College. He started his career working in financial risk management at State Street before transitioning to the analysis of the personal insurance market. He's also a five-time Jeopardy champion!

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