Medicare Part C is an alternative way to get your Medicare coverage through a private insurance company

Medicare Part C, also called Medicare Advantage, is a plan sold by private insurance companies that bundles your hospital coverage (Part A), doctor visits (Part B), and usually prescription drugs (Part D) into one plan. Instead of getting coverage directly from Medicare, you pay the private insurer a monthly premium, and they handle your benefits. You still pay Medicare a monthly premium for Part B, and the insurance company receives a payment from Medicare for taking you on.

The main draw of Part C is that it often costs less out of pocket than Original Medicare plus a separate drug plan, and many plans include dental, vision, or hearing coverage that Original Medicare does not. The trade-off is that you must use doctors and hospitals in the plan's network, and you may need approval before certain treatments.

Key Takeaways

  • Medicare Part C combines hospital, doctor, and usually drug coverage into one private plan, whereas Original Medicare keeps these as separate parts you manage yourself.
  • Part C plans often have lower monthly premiums and include extras like dental or vision, but you must use in-network providers or pay more.
  • You can switch plans or return to Original Medicare during the Annual Enrollment Period (October 15 to December 7 each year) or if you may have access to for a Special Enrollment Period.
  • Part C plans have annual out-of-pocket limits, meaning your costs stop once you reach a certain amount, whereas Original Medicare does not have this cap.

How Part C differs from Original Medicare

Original Medicare is run by the federal government and lets you see any doctor or hospital that accepts Medicare. You get Part A (hospital) and Part B (doctor visits) separately, and you pay for them with different deductibles and copays. Many people add a Medigap policy to cover costs that Medicare does not, and a separate Part D plan for prescriptions.

Part C bundles these into one private plan. You do not choose between Part A and Part B — the plan includes both. But you give up the freedom to see any provider. Instead, you choose from doctors and hospitals in that plan's network. If you go out of network, you pay more or the plan may not cover it at all. Some Part C plans are Health Maintenance Organizations (HMOs), which require you to pick a primary care doctor and get referrals for specialists. Others are Preferred Provider Organizations (PPOs), which let you see specialists without a referral but charge more for out-of-network care.

What Part C plans cover and what they cost

Every Part C plan must cover everything Original Medicare covers: hospital stays, doctor visits, emergency care, and preventive services. Most plans also include prescription drug coverage (Part D), so you do not need a separate drug plan. Many plans add benefits Original Medicare does not pay for, such as dental cleanings, eyeglasses, hearing aids, or fitness programs.

The monthly premium for Part C varies by plan and by where you live. Some plans have a zero premium, meaning you pay only your Part B premium to Medicare and nothing to the insurance company. Others charge $50 to $200 or more per month. You also pay copays or coinsurance when you use services — for example, $20 to see your doctor or $300 for an emergency room visit. Part C plans have an annual out-of-pocket maximum, usually between $5,000 and $7,000. Once you reach that limit in a year, the plan covers 100 percent of covered services for the rest of the year. Original Medicare has no such cap.

When you can enroll in or switch Part C plans

If you are new to Medicare, you can enroll in Part C during your Initial Enrollment Period, which is the seven-month window that includes the month you turn 65 and the three months before and after. If you miss this window, you may face a late enrollment penalty.

If you already have Original Medicare or another Part C plan, you can switch during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect January 1. You can also switch if you may have access to for a Special Enrollment Period — for example, if you move out of your plan's service area, lose employer coverage, or experience a major life event like the death of a spouse.

You can return to Original Medicare from Part C at any time during the Annual Enrollment Period. If you switch back to Original Medicare, you may want to enroll in a Medigap policy and a Part D drug plan to cover costs that Original Medicare does not pay.

Network restrictions and prior authorization

Part C plans limit which doctors and hospitals you can use. Before you enroll, check whether your current doctors are in the plan's network. If your doctor is not in the network, you will either have to switch doctors or pay out of pocket for their care. Some plans allow out-of-network care in emergencies or urgent situations, but the cost to you is usually much higher.

Many Part C plans require prior authorization before you have certain procedures or tests. This means your doctor must get approval from the insurance company before you have the service, or the plan may not pay for it. This can delay treatment, so ask your doctor's office whether prior authorization is needed before scheduling.

Part C and prescription drugs

Most Part C plans include prescription drug coverage, so you do not need a separate Part D plan. The plan's drug formulary (the list of covered medications) may differ from other plans, so check whether your regular medications are covered and at what cost. Some drugs may require prior authorization or a step therapy, meaning you must try a cheaper drug first before the plan will pay for a more expensive one.

If your Part C plan does not include drug coverage, you can enroll in a standalone Part D plan during the Annual Enrollment Period. However, if you go without drug coverage when you are first may be able to access, you may owe a late enrollment penalty when you do enroll.

Frequently Asked Questions

Can I use my Part C plan if I travel out of state?

Most HMO plans cover emergency care anywhere in the United States, but routine care is usually only covered in-network. PPO plans often cover out-of-network care at a higher cost. Check your plan's coverage rules before you travel, and carry your insurance card with you.

What happens to my Part C plan if I move?

If you move outside your plan's service area, you can switch to a different Part C plan or return to Original Medicare without waiting for the Annual Enrollment Period. Contact your current plan to report the move and learn your options.

Do I still pay Medicare premiums if I have Part C?

Yes. You pay your Part B premium to Medicare each month, just as you would with Original Medicare. Your Part C plan may charge an additional monthly premium on top of that, though some plans have zero premium.

Can I switch from Part C back to Original Medicare anytime?

You can switch during the Annual Enrollment Period (October 15 to December 7) or if you may have access to for a Special Enrollment Period. Outside these windows, you are locked into your plan for the year.

What is the difference between a Part C HMO and a PPO?

HMOs require you to choose a primary care doctor and get referrals for specialists, and they usually do not cover out-of-network care except emergencies. PPOs let you see specialists without referrals and cover some out-of-network care, but they charge higher copays and coinsurance.