What Is Medicare Part C?

What is Medicare Part C and how does it work? Read on to find out.

Medicare can be quite complex and difficult to sort through. In order to make it simpler to grasp, the program has been divided into four fundamental parts that provide coverage for a wide range of items; from hospital care to appointments with your doctor to prescription medicines. Medicare Part C is also known as Medicare Advantage. You can get it through private insurance companies contracted with Medicare. Medicare Part C provides coverage for everything that Original Medicare (Part A and Part B) cover along with many extra benefits as well. Learn more about what is Medicare Part C in this detailed article.

What is Medicare Part C?

Medicare Advantage, or Part C, is an alternative to original Medicare and you can get it through private insurance companies. An individual signed up for Part A and Part B can join a Medicare Advantage plan. Along with hospital (Part A) and medical (Part B) coverage, most Advantage (Part C) plans also provide coverage for:

  • prescription drugs
  • dental, vision, and hearing care
  • additional perks, such as gym memberships

You might even get coverage for fitness programs (like gym memberships), transportation services to travel to your medical appointments, and over-the-counter medication. Moreover, certain plans provide benefits that are customized to specific chronic conditions. The Centers for Medicare and Medicaid Services sets the guidelines for Medicare, and during recent years, it has permitted Medicare Advantage plans to cover extra benefits, wheelchair ramps and shower grips for your home, meal delivery, and transportation services to and from your doctors’ appointments. Medicare Advantage provides various benefits via many different plan options. Individuals can choose from these plans, the one which best caters to their medical situation.

Medicare Advantage belongs to the Medicare program which is available to older citizens and disabled adults who are eligible. As mentioned before, it is also known as a Part C plan and instead of the federal government, it is offered by private insurance organizations. Moreover, it also offers the same Part A hospital and Part B medical coverage which is provided by Original Medicare. However, hospice care is not included. Some Part C plans also cover Part D prescription medication. Individuals who enroll in a Medicare Advantage plan still have Medicare.

Just like non-Medicare health insurance, Medicare Part C has various types, with different criteria for finding care providers. For instance, when it comes to an HMO plan, you will be required to see in-network health care providers unless it is an emergency, and you need a referral to see a specialist. In a PPO plan, you can see both in-network and out-of-network health care providers. Nevertheless, you typically pay more to go out of network.

Organizations offering Medicare Part C must follow specific rules set by federal and state law, but out-of-pocket expenses and guidelines for accessing services may vary from one plan to another. Moreover, companies can change those aspects from year to year. Make sure that you compare each plan’s rules, benefits, and expenses before selecting one that is right for you.

How does Medicare Part C work?

For the most part, Medicare is accessible for individuals who are 65 years old or more, young individuals with disabilities, and individuals with end-stage renal illness — permanent kidney failure requiring dialysis or transplant — or amyotrophic lateral sclerosis (ALS). Furthermore, Medicare Part C (also known as Medicare Advantage plans) plans are offered by privately owned businesses that are Medicare-endorsed. They are viewed as an option in contrast to Original Medicare and cover every bit of the costs brought about under Medicare. Some Medicare Part C plans cover extra expenses that are not paid for by Medicare including vision, dental, and hearing costs. Medicare also pays for the expenses for members in Medicare Advantage plans. In addition to this, Medicare Advantage plans don’t work with Medigap, which is likewise called Medicare Supplement Insurance.

The average month-to-month expense for a Medicare Advantage plan in 2021 is predicted to drop 11% to about $21 from an average of $23.63 in 2020. Privately owned businesses get a proper sum every month for Medicare Advantage plan care. Thus, these organizations can charge cash-based expenses for policyholders and can set up their own standards for administration, for example, the requirement for referrals or supplier networks for both non-serious care and crisis administrations.

Regional preferred provider organizations (PPOs) were set up to give country recipients more prominent admittance to Medicare Advantage plans and cover whole statewide or multi-state areas. Regional PPOs represented 5% of all Medicare Advantage enrollees in 2020. Around 24 million individuals, or 36% of those getting Medicare benefits, were taken on a Medicare Advantage plan in 2020. That number is predicted to increase to almost more than 26 million in 2021.

What are the Part C network types?

Let us look at the different types of Medicare Part C plans:

  • HMO (Health Maintenance Organization): Nearly 66% (62%) of all Medicare Advantage enrollees are in HMOs. HMOs by and large only cover services performed by in-network providers with the exception of medically important crisis care. Premiums and cost-sharing (deductibles, copays, coinsurance) can be lower for HMOs.
  • PPO (Preferred Provider Organization): Almost a third (31%) of Medicare Advantage enlistment in 2019 was in PPOs. PPOs offer a more prominent selection of doctors and emergency clinics yet can be a more costly choice. They cover care by all through network providers however at a greater expense to the planning part.
  • Different kinds of Medicare Advantage plans: few recipients have the choice of Private Fee-for-Service (PFFS) plans and Medicare Medical Savings Accounts (MSA) plans.
  • Special Needs Plans (SNPs) for those qualified for both Medicare and Medicaid).
  • Group plans supported by certain businesses or associations are accessible to some Medicare recipients.

The essential requirements to sign up for one of these plans include living in the plan’s service region and having Medicare Parts A and B. HMO point-of-service (HMOPOS) plans and medical bank account (MSA) plans are more uncommon.

Medicare Advantage plans have been inaccessible to individuals who have an end-stage renal disease (ESRD) except if they could discover an ESRD special needs plan close by. However, beginning in 2021, individuals with ESRD will actually want to pursue any Medicare Advantage plan in their locality. The individuals who have ESRD should look at the expenses of Medical Advantage plans versus Original Medicare in addition to Medigap and a Part D plan, and watch that their primary care physicians and emergency clinic are in-network with any MA plan they are thinking about.

What does Medicare Part C cover?

Medicare Advantage plans should cover all that Original Medicare covers, including inpatient clinic and talented nursing office care, crisis and earnest consideration, specialist visits, medical procedure, preventive care, certain vaccines, and medical gear like wheelchairs and walkers.

Furthermore, Medicare Advantage plans may likewise cover extra services excluded from Part A and Part B. Most plans (90%) incorporate Part D prescription drug coverage. Many offer some coverage for dental and vision care, portable hearing assistants, and gym/fitness centers. As of late, these plans have been allowed to give different advantages, including adult daycare, in-home help services, and home security alterations, for example, grab bars and wheelchair inclines. Conventional Medicare does commonly not cover those services.

What does Medicare Part C cover compared to Original Medicare?

Medicare Part C plans cover Part A and Part B, and many additionally incorporate prescription drug coverage (Part D) and other different advantages that are not accessible with Original Medicare. That is the reason, of the around 64 million individuals who applied for Medicare, almost 22 million of them picked Medicare Advantage plans.

Original Medicare incorporates Part A and Part B. Part A covers hospitalization, home consideration, and other inpatient medical needs. Part B covers outpatient care, for example, visits to the doctor, medical tests, screenings, and preventive considerations.

Many individuals might require more coverage for their health needs. For instance, Original Medicare doesn’t have doctor-prescribed medication coverage. Private guarantors offer Medicare Part D coverage, yet and, after it’s all said and done, there still might be areas of your healthcare where you need insurance. That is the place where Medicare Part C plans come in.

What is Medicare Part C coverage for inpatient care?

When it comes to Original Medicare, inpatient care is by and large covered by Medicare Part A. Medicare Part C covers similar advantages as Medicare Part A including:

  • Inpatient care in a hospital
  • Inpatient skilled nursing facility care

Medicare care Part C additionally covers home health care. In addition to this, Medicare Part C might have distinctive expense sharing sums for inpatient care and home health care than Original Medicare has. With Medicare Advantage, your hospice care advantages will in any case be covered by Original Medicare.

What is Medicare Part C coverage for outpatient care?

When it comes to Original Medicare, outpatient care is by and large covered by Medicare Part B. Outpatient care incorporates medically essential services and preventive services to forestall or identify sickness. Medicare Part C covers similar advantages as Medicare Part B including:

  • Doctor visits (primary care doctor and specialists)
  • Laboratory tests and X-rays
  • Ambulance services in an emergency
  • Both inpatient and outpatient mental health services
  • Durable medical equipment such as walkers and wheelchairs
  • Preventative tests and vaccines, including flu shots
  • Physical therapy
  • Occupational therapy
  • Speech and language pathology

Moreover, Medicare Part C might have different cost-sharing amounts for outpatient care as compared to Original Medicare.

What is Medicare Part C coverage for extra benefits?

Unlike Original Medicare, Medicare Part C by and large offers coverage for professionally prescribed medications you take at home. The specific physician-endorsed drugs that are shrouded are recorded in the plan’s formulary. Formularies might differ from one plan to another. Other additional advantages that Medicare Part C might cover include:

  • Routine vision care including contacts and eyeglasses
  • Routine dental care including cleanings, x-rays, and dentures
  • Routine hearing care including hearing aids
  • Fitness benefits including exercise classes

Not all Medicare Part C plans cover additional advantages similarly. For instance, some Medicare Part C plans may just cover “Federal health insurance covered dental advantages” which by and large just means dental consideration in case of a mishap or illness of the jaw. On the off chance that your Medicare Part C covers dental advantages all the more widely, you might have a higher month-to-month premium for that coverage.

Who is eligible for Medicare Part C?

Anybody more than 65 years old who has tried out Medicare Part A and Part B might settle on a Medicare Advantage plan that serves in their geographic region. A special case is individuals with end-stage renal disease (ESRD), which requires normal dialysis or a kidney transplant, are not qualified. In any case, in case you were at that point tried out a Medicare Advantage plan and created ESRD, you can keep your plan; you could likewise select a Special Needs Plan. In case you are getting Social Security Disability (SSDI) benefits, you will be selected consequently in Medicare when you become qualified, typically after you have been getting SSDI benefits for a very long time.

How much do Medicare Part C plans cost?

Medicare Part C costs are based on a variety of factors. The most common expenses within your plan will be:

  • your Part B monthly premium, which may be covered by your Part C plan
  • your out-of-pocket costs, which include copayments and coinsurance
  • your Medicare Part C costs, which include a deductible and monthly premiums

Premiums: Medicare Advantage plans generally have next to zero month-to-month premium. The average premium for Medicare Advantage is about $21 in 2021. Remember that premiums change across the nation. Enrollees actually need to pay their Medicare Part B premium ($148.50 every month for 2021, deducted from your Social Security check on the off chance that you get benefits).

Deductible: Before your coverage kicks in, you might need to meet a deductible. While some Medicare Advantage plans have separate deductibles for medical consideration and physician-recommended drugs, others don’t.

Copayments: Copayments of $10 or $20 might be required each time you see a specialist or visit a lab. Additionally, you will confront everyday copayments in the event that you invest energy in an emergency clinic. Consider your medical utilization to appraise the amount of these costs you’re probably going to need to pay.

Coinsurance: With Original Medicare, you are liable for 20% of endorsed costs. In numerous Medicare Advantage plans, you will pay coinsurance for expensive medical services, like diagnostic imaging, chemotherapy, radiation, and dialysis, or in some PPO plans, a level of the expense for out-of-network services.

Out-of-pocket maximum: Medicare Advantage plans are needed to restrict your out-of-pocket spending. In-network costs are covered at a maximum of $7,550 per year, while in-network and out-of-network charges consolidated maximize at $11,300.10 In Original Medicare, there is no restriction to what your 20% portion of medical costs can mount up to in an awful health year.

Medicare costs in some major cities

The following are some comparisons of expenses for Medicare Part C plans in some significant metropolitan cities across the United States. Each of the plans recorded beneath covers doctor prescribed medications, vision, dental, hearing, and fitness benefits. Notwithstanding, they all vary in cost.

New York, NY

One insurance company offers an HMO plan that costs:

monthly premium: $0

health deductible: $0

drug deductible: $350

in-network out-of-pocket max: $7,550

primary doctor visit copay: $10

specialist visit copay: $45

Atlanta, GA

One insurance company offers a PPO plan that costs:

monthly premium: $0

health deductible: $0

drug deductible: $0

in- and out-of-network out-of-pocket max: $11,300

in-network primary doctor visit copay: $5

in-network specialist visit copay: $35

Dallas, TX

One insurance company offers an HMO plan that costs:

monthly premium: $0

health deductible: $0

drug deductible: $250

in-network out-of-pocket max: $5,900

primary doctor visit copay: $0

specialist visit copay: $40

Chicago, IL

One insurance company offers an HMO Point-of-Service plan that costs:

monthly premium: $0

health deductible: $0

drug deductible: $0

in-network out-of-pocket max: $3,900

in-network primary doctor visit copay: $0

in-network specialist visit copay: $40

Los Angeles, CA

One insurance company offers a PPO plan that costs:

monthly premium: $89

health deductible: $750

drug deductible: $0

in-network out-of-pocket max: $7,550

in-network primary doctor visit copay: $10

in-network specialist visit copay: $40

Note that these cost estimations were taken from Medicare.gov and do exclude any variables exceptional to your circumstance, for example, how much your professionally prescribed medications might cost or whether you get some sort of monetary help or not.

When can I enroll?

You can enroll in Medicare Part C during any of the following periods:

Initial enrollment period (IEP). IEP is the multi-month period that starts three months before your 65th birthday celebration and enrollment in Parts A and B. During this time, you can choose to have Original Medicare (Parts A and B) or add additional coverage with a Medicare Advantage or Medigap plan.

Open enrollment period (OEP). OEP runs from Oct. 15 – Dec. 7 every year and is by and large the one season you can make changes to your plan. In the event that you don’t as of now have a Medicare Advantage plan, you can decide to enroll in one during this time. In case you are presently enrolled in a Medicare Advantage plan, you can pick an alternate plan. Moreover, if you do choose to make changes, your coverage is powerful on Jan. 1.

Medicare Advantage Open Enrollment Period (MAOEP). From January 1 to March 31 every year, you can change from one Medicare Advantage plan to the next or get back to Original Medicare and enroll in Part D prescription drug coverage.

Special election period (SEP). These are periods outside of the ICEP or AEP when an individual can change their present plan. A few examples are:

  • If you move outside the plan’s service area
  • If you are enrolled in both Medicare and Medicaid
  • If you qualify for a low-income subsidy
  • If you lose creditable drug coverage from your employer
  • If your plan is no longer offered
  • If your plan is terminated by Medicare

How to enroll in a Medicare Part C plan?

To enroll in an Advantage plan, an individual first needs to choose a plan in their locality. After they settle on a plan, they might demand an enrollment form from the insurance organization offering it or enroll on the organization’s site. In case you are applying for Medicare for the first time, you can pick a Medicare Advantage plan during the Initial Enrollment Period (IEP). This is the seven-month period that incorporates:

  • Three months before your 65th birthday
  • Your 65th birthday month
  • Three months after your 65th birthday

In case you’re as of now enrolled in Original Medicare, you can change to a Medicare Advantage (Part C) plan during the Open Enrollment Period (OEP), which is October 15 to December 7. In case you’re as of now enrolled in a Medicare Advantage plan, you can even change to an alternate one during this time. You additionally get an opportunity to change your Medicare Advantage plan from January 1 to March 31 during the Medicare Advantage Open Enrollment Period.

Do you need Medicare Part C?

Although these plans are discretionary, however, on the off chance that you need coverage that is beyond the essential hospital and medical insurance, Medicare Part C may be a decent alternative for you. In case you’re content with your present Medicare coverage and are just keen on getting physician-recommended drug coverage, an independent Medicare Part D plan might be the most ideal choice. On the off chance that you have Medicare coverage, however, you just need extra assistance with costs, a Medicare supplemental insurance (Medigap) strategy may work for you. In addition to this, for certain individuals, Medicare Part C is an extra expense that they can’t afford — for this situation, looking for Part D and Medigap coverage might assist with setting aside cash.

What is the difference between Medicare Part C and Part D?

Medicare Part C gives more coverage to regular healthcare incorporating doctor prescribed medication coverage for certain plans when joined with Part D. A Medicare Advantage prescription drug (MAPD) plan is the point at which a Part C and Part D plan are joined. Medicare Part D just covers professionally prescribed medications. If you have Original Medicare and simply need a plan for prescription drugs, Medicare Part D is the most ideal decision. At the point when you require more coverage for dental, vision, or doctor-prescribed medications, Medicare Part C plans are ideal as they give more choices to accommodate your healthcare needs.

What are the pros and cons of Medicare Part C?


Lower upfront expenses. A few plans don’t charge a monthly premium. The average premium is usually $29 per month.

One-stop shopping. Most plans incorporate Part D medication insurance, so that saves you from shopping for a Part D plan and paying its premiums. Additionally, Medicare Advantage saves the expenses of a Medicare Supplement plan, which most Original Medicare enrollees purchase to help pay the 20% of costs that are their responsibility. Those expenses additionally incorporate different deductibles and cost-sharing, similar to the Part A hospitalization deductible. Moreover, for a 65-year-elderly person, these arrangements range from $118 to $464 each month, albeit a more affordable high-deductible plan is additionally accessible.

Cap on out-of-pocket costs. Medicare Advantage has a cap on your out-of-pocket going through $7,550 per year for in-network charges and $11,300 for a combination of in-network and out-of-network charges. Original Medicare has no cap.


Restricted choices of providers and hospitals. HMOs for the most part expect you to utilize only providers in their organization. In PPOs, you will for the most part cover a greater amount of the bill when you use out-of-network providers. Original Medicare permits you to utilize any provider or emergency clinic that acknowledges Medicare, and by far most do.

Geographical limits. Care may not be covered in case it’s outside of the plan’s geographic region. Original Medicare permits care anyplace in the country. Geographical limits might be risky for individuals who travel often or have homes in two regions.

Pre authorizations and referrals might be required. Medicare Advantage plans might expect referrals to see specialists and need the earlier authorization of strategies. Issues with the refusal of care and installment are “widespread” in Advantage plans, as indicated by a new government report. Attempt to pick a plan that is exceptionally appraised by individuals. You can discover appraisals for plans in your state at NCQA. Or then again consult the star appraisals of value and performance for plans in the Medicare Plan Finder.


Now that you have read this article, you know all about what is Medicare Part C. It is simply one more name for Medicare Advantage, which is an across-the-board option in contrast to Original Medicare — which means it replaces Medicare Part A (hospital coverage), Medicare Part B (medical insurance), and often Medicare Part D (drug coverage). Medicare Part C plans are offered by private organizations that have been endorsed by Medicare. Most plans give benefits that aren’t covered under Original Medicare, like dental, hearing, and vision coverage.

John Otero

John Otero

John Otero is an industry practitioner with more than 15 years of experience in the insurance industry. He has held various senior management roles both in the insurance companies and insurance brokers during this span of time. He began his insurance career in 2004 as an office assistant at an agency in her hometown of Duluth, MN. He got licensed as a producer while working at that agency and progressed to serve as an office manager. Working in the agency is how he fell in love with the industry. He saw firsthand the good that insurance consumers experienced by having the proper protection. John has diverse experience in corporate & consumer insurance services, across a range of vocations. His specialties include Major Corporate risk management and insurance programs, and Financial Lines He has been instrumental in making his firm as one of the leading organizations in the country in generating sustainable rapid growth of the company while maintaining service excellence to clients.