Part C covers the same services as Original Medicare, but through a private insurance company

Part C, also called Medicare Advantage, is a way to receive your Medicare benefits through a private insurance plan instead of directly from the federal government. Part C plans must cover everything that Original Medicare (Parts A and B) covers — hospital stays, doctor visits, and medical equipment. Most Part C plans also include prescription drug coverage and extra benefits like dental or vision care that Original Medicare does not pay for.

The trade-off is that Part C plans have networks. You usually must see doctors and hospitals that are in your plan's network, except in emergencies. If you go out of network, you may pay more or the plan may not cover the visit at all. Part C plans also have yearly limits on what you pay out of pocket, which can protect you from very high costs.

Key Takeaways

  • Part C covers hospital care, doctor visits, and medical equipment the same way Original Medicare does, but you receive benefits through a private insurance company.
  • Most Part C plans include prescription drug coverage and additional benefits like dental, vision, or hearing aids that Original Medicare does not cover.
  • You must use doctors and hospitals in your plan's network for routine care, and out-of-network visits may cost you more or not be covered.
  • Part C plans have a yearly out-of-pocket spending limit, which means your costs stop once you reach that amount.
  • You can only enroll in Part C during specific times of year, usually in the fall or if you have a major life change.

Hospital and doctor care covered under Part C

Part C covers inpatient hospital stays, including semi-private rooms, meals, and standard nursing care. If you need surgery or emergency care, your hospital stay is covered the same way it would be under Original Medicare Part A. You pay a copay or coinsurance amount depending on your specific plan.

Doctor visits are covered for routine checkups, treatment of ongoing conditions, and specialist care. You choose a primary care doctor from your plan's network, and you typically need a referral from that doctor to see a specialist. Each visit has a copay — usually between $10 and $50 depending on the plan — rather than the coinsurance you would pay under Original Medicare.

Preventive care like annual wellness visits, cancer screenings, and vaccinations are covered at no cost to you, just as they are under Original Medicare. Mental health services, including therapy and psychiatric care, are also covered when provided by in-network providers.

Prescription drugs and additional benefits

Most Part C plans include prescription drug coverage built in, so you do not need to buy a separate Part D plan. Your medications are covered through your Part C plan's formulary, which is the list of drugs the plan pays for. 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.

Beyond the basics, Part C plans often cover services that Original Medicare does not pay for at all. These may include dental care (cleanings, fillings, or extractions), vision care (eye exams and glasses), hearing aids, or fitness programs. Some plans cover transportation to medical appointments or over-the-counter items like pain relievers or cold medicine. The specific extra benefits vary widely from plan to plan and from year to year.

You should review your plan's summary of benefits each year, because the extra benefits and their coverage levels can change. A plan that covered dental work one year might offer less coverage the next year, or a new plan in your area might offer benefits your current plan does not.

Medical equipment and supplies

Part C covers durable medical equipment — items like wheelchairs, walkers, oxygen equipment, and hospital beds — the same way Original Medicare does. Your doctor must order the equipment, and it must be medically necessary. You typically pay 20% of the cost after you meet your deductible, though some Part C plans have different cost-sharing for equipment.

Diabetic supplies, including test strips, lancets, and glucose monitors, are covered. Ostomy supplies and other medical supplies prescribed by your doctor are also included. The copay or coinsurance for supplies depends on your plan.

What Part C does not cover

Part C does not cover services that Original Medicare does not cover. This means long-term care in a nursing home or assisted living facility is not covered — Part C pays for skilled nursing care for a limited time after a hospital stay, but not for custodial care or permanent residence. Hearing aids may be covered by some Part C plans, but hearing exams are not always included.

Routine dental care, eye exams, and glasses are not covered by Original Medicare, but many Part C plans do cover them as an extra benefit. However, not all plans include these, and the coverage limits vary. Cosmetic procedures, fertility treatments, and weight-loss surgery are not covered unless they are medically necessary for a specific condition.

If you travel outside the United States, Part C coverage usually does not explore except in limited situations. Some plans offer emergency coverage while you are traveling, but routine care abroad is not covered. Original Medicare has the same limitation.

How Part C costs work

You still pay your Part B premium to Medicare each month — Part C does not replace that. On top of that, many Part C plans have a monthly premium, though some plans have a $0 premium. You also pay a yearly deductible before the plan starts to pay for most services, though preventive care is covered before you meet your deductible.

Each time you see a doctor or fill a prescription, you pay a copay or coinsurance. These costs add up toward your yearly out-of-pocket maximum — the most you will pay in a calendar year. Once you reach that limit, the plan pays 100% of your covered services for the rest of the year. This is different from Original Medicare, which has no yearly limit on what you pay.

If you use out-of-network providers, you may pay more or the visit may not be covered at all. Emergency care is covered even if you go to an out-of-network hospital, but you should try to use in-network providers whenever possible to keep your costs down.

When you can enroll in Part C

You can enroll in Part C during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Coverage begins on January 1 of the following year. If you are new to Medicare, you have a seven-month window that includes the month you turn 65 and the three months before and after.

If you have a major life change — such as moving out of your plan's service area, losing other health coverage, or becoming may be able to access for Medicaid — you may be able to enroll in Part C outside the regular enrollment period. You must contact Medicare within 60 days of the change to see if you may have access to for a Special Enrollment Period.

Once you are enrolled in a Part C plan, you are locked in for the year. You cannot switch to a different plan or to Original Medicare until the next Annual Enrollment Period, unless you may have access to for a Special Enrollment Period.

Questions to ask your doctor and your plan

Before you enroll in a Part C plan, ask your current doctors whether they are in the plan's network. If your doctor is not in the network and you want to keep seeing them, you may need to choose a different plan. Ask whether you need a referral to see specialists, because some plans require them and others do not.

Contact the Part C plan directly and ask about the formulary — specifically, whether your current medications are covered and at what copay amount. Ask about the yearly out-of-pocket maximum and what services are covered before you meet your deductible. If you use medical equipment or supplies regularly, ask how those are covered and what your costs will be.

Ask whether the plan covers services you use frequently, such as physical therapy, mental health care, or dental work. Find out whether the plan covers care when you travel, and what the process is for emergency care outside the network.

Frequently Asked Questions

Can I switch from Part C back to Original Medicare?

Yes, but only during the Annual Enrollment Period (October 15 to December 7) or if you may have access to for a Special Enrollment Period due to a major life change. If you switch back to Original Medicare, you may want to enroll in a separate Part D plan for prescription drug coverage and a Medigap plan to cover costs that Original Medicare does not pay.

What happens if my doctor leaves my Part C plan's network?

If your doctor stops accepting your plan, you can usually continue seeing them for a short transition period while you find a new in-network doctor. Contact your plan to ask about the transition rules. If you cannot find an acceptable replacement doctor, you may be able to switch to a different Part C plan outside the regular enrollment period.

Does Part C cover care at urgent care clinics?

Yes, if the clinic is in your plan's network. Urgent care is covered the same way as a doctor's office visit, with a copay. If you go to an out-of-network urgent care clinic, you may pay more or the visit may not be covered, so check your plan's network before you go.

Can I have Part C and Medigap at the same time?

No. If you are enrolled in Part C, you cannot buy a Medigap policy. Medigap is designed to work with Original Medicare, not with Part C. Part C plans already include some cost protection through the yearly out-of-pocket maximum.

What if I move to a different state?

Part C plans are regional and do not follow you if you move out of the service area. You will need to enroll in a new Part C plan in your new state, or switch to Original Medicare. Contact Medicare as soon as you know you are moving so you can understand your options before your move date.