Medicare Part C is an all-in-one alternative to Original Medicare

Medicare Part C, also called Medicare Advantage, is a way to get your Medicare benefits through a private insurance company instead of through the government's Original Medicare (Parts A and B). The insurance company contracts with Medicare to provide the same hospital and doctor coverage you would get otherwise, but often with additional benefits like prescription drug coverage, dental, vision, or hearing aids built in.

Part C plans must cover everything that Original Medicare covers — hospital stays, doctor visits, emergency care, and preventive services. But they can add their own rules about which doctors you can see, how much you pay, and what extra services they include. You still pay your Part B premium to Medicare, plus whatever premium the Part C plan charges.

Key Takeaways

  • Medicare Part C covers all the same hospital and doctor services as Original Medicare, but through a private insurance company that sets its own rules about networks and costs.
  • Most Part C plans include prescription drug coverage, dental, vision, or hearing benefits that Original Medicare does not cover on its own.
  • You must use doctors and hospitals in the plan's network in most cases, and you pay copays or coinsurance rather than the deductibles and percentages of Original Medicare.
  • Your out-of-pocket costs are capped each year, so you know the maximum you will pay, unlike Original Medicare which has no annual limit.
  • You can switch to a different Part C plan or back to Original Medicare once a year during the Annual Enrollment Period in the fall.

Hospital and doctor coverage under Part C

Part C plans cover hospital stays, doctor office visits, specialist care, lab tests, X-rays, and emergency room visits the same way Medicare requires them to. You do not pay a separate deductible for hospital care the way you do in Original Medicare — instead, you pay a copay (a flat amount like $250) or coinsurance (a percentage of the cost). The plan decides what that copay or coinsurance is, so it varies from plan to plan.

The major difference is that most Part C plans use a network. This means you must see doctors and use hospitals that have a contract with your plan. If you see an out-of-network doctor without permission, you pay more or the plan may not cover it at all. Some plans, called PPOs, let you see out-of-network doctors but charge you higher copays. HMO plans, the most common type, usually require you to pick a primary care doctor and get a referral to see a specialist.

Preventive services — like annual wellness visits, cancer screenings, vaccines, and blood pressure checks — are covered at no cost to you, just as they are in Original Medicare. Part C plans cannot charge you a copay for these preventive visits.

Prescription drug coverage included in most plans

Most Part C plans include prescription drug coverage (Part D) as part of the plan, so you do not need to buy a separate drug plan. The plan covers brand-name and generic medications on a formulary — a list of drugs the plan covers. You pay a copay for each prescription, and the amount depends on which tier the drug is on (generic drugs cost less than brand-name drugs).

If your Part C plan does not include drug coverage, you can buy a separate Part D plan. However, if you go without drug coverage for more than 63 days in a row, you may have to pay a penalty if you join a drug plan later.

Part C plans have an annual out-of-pocket maximum for drugs and medical services combined. Once you reach that limit, the plan pays for the rest of your covered care for the rest of the year. Original Medicare has no such limit, which is one reason some people prefer it.

Dental, vision, and hearing benefits

Original Medicare does not cover dental work, eye exams, glasses, or hearing aids. Many Part C plans add these benefits because they can offer them at a lower cost than you would pay buying them separately. Some plans cover routine dental cleanings and exams. Others cover major dental work like crowns or root canals, though usually with a limit on how much they will pay per year.

Vision coverage in Part C plans typically includes an annual eye exam and a set amount toward glasses or contact lenses. Hearing benefits often cover hearing aids or hearing aid exams, though the amount varies widely by plan.

Not every Part C plan includes these benefits, and the coverage amounts differ from plan to plan. When you are comparing plans, check what dental, vision, and hearing services each one covers and whether there are limits on how much they will pay.

What Part C does not cover

Part C covers the same services that Original Medicare covers, which means it does not cover long-term care in a nursing home (skilled nursing facility care is covered for a limited time after a hospital stay, but custodial care is not). It does not cover hearing aids in all plans, though many now do. It does not cover routine foot care, most dental work unless your plan adds it, or most vision care unless your plan adds it.

Part C also does not cover services outside the United States except in limited cases. If you travel outside the country, check your plan's rules about emergency care abroad.

Out-of-pocket costs and annual limits

Part C plans have an annual out-of-pocket maximum — a cap on how much you will pay in copays and coinsurance in a year. Once you reach that limit, the plan pays for all covered services for the rest of the year. This maximum varies by plan and by year, but it gives you a way to predict your worst-case costs. Original Medicare has no such limit.

You still pay your monthly Part B premium to Medicare (currently $164.90 per month for most people in 2024, though this changes yearly). Many Part C plans charge an additional monthly premium on top of that, though some plans have zero premium. Plans with lower premiums often have higher copays, and plans with higher premiums may have lower copays. You trade off premium cost against out-of-pocket costs when you choose a plan.

How to compare Part C plans and make changes

Every fall during the Annual Enrollment Period (October 15 to December 7), you can switch to a different Part C plan, switch to Original Medicare, or switch from Original Medicare to Part C. You cannot make changes outside this window unless you have a may have access to life event like moving to a new state or losing other insurance.

To compare plans, use Medicare.gov's plan comparison tool. Enter your zip code, the doctors and hospitals you want to use, and the medications you take. The tool shows you which plans include your doctors in their network, what your copays would be, and what your estimated annual costs would be. You can also call 1-800-MEDICARE to speak with someone who can walk you through the comparison.

If you switch to a Part C plan, your coverage starts January 1 of the following year. If you switch back to Original Medicare, you may want to buy a Medigap policy at the same time to cover costs that Original Medicare does not pay. Medigap policies have their own enrollment rules, so talk to your insurance agent or call Medicare if you are making this change.

Frequently Asked Questions

Can I use my current doctor with a Part C plan?

It depends on the plan. Most Part C plans use a network of doctors and hospitals. Before you join a plan, check whether your current doctor is in the network. If your doctor is not in the network, you can either choose a different plan or switch to Original Medicare. Medicare.gov's plan comparison tool lets you search by doctor name.

What happens if I need care outside my plan's network?

In an HMO plan, out-of-network care is usually not covered except in emergencies. In a PPO plan, out-of-network care is covered but you pay a higher copay or coinsurance. Always check your plan's rules before you see an out-of-network doctor, and ask the doctor's office whether they are in your plan's network.

Do Part C plans cover mental health services?

Yes. Part C plans must cover mental health services the same way Original Medicare does — office visits with a psychiatrist or therapist, inpatient psychiatric hospital care, and partial hospitalization programs. Your copay for mental health visits is usually the same as your copay for a regular doctor visit, though some plans charge differently.

Can I have both Part C and a Medigap policy?

No. If you are enrolled in a Part C plan, you cannot buy a Medigap policy. Medigap policies are designed to work with Original Medicare. If you switch from Part C to Original Medicare, you can then buy a Medigap policy, though you may pay more if you do not buy it right away.

What should I ask my doctor before switching to Part C?

Ask whether your doctor is in the Part C plan's network and whether they accept that plan's insurance. Ask about any specialists you see regularly and whether they are in the network too. If your doctor is not in the network, ask whether they can refer you to someone in the plan who provides the same care.