Medicare Part C: What It Is and What It Covers

Individuals aged 55 and older may reside in their homes or independent living facilities and have limited medical needs and bills. Over time, their health may decline, requiring more expensive medical treatments. Paying these bills after retirement while on a fixed income and collecting social security can become increasingly difficult.

Millions of Americans age 65 and older receive health care insurance through Medicare to afford necessary medical services, equipment, and medications. With several Medicare options, it can be difficult to know which plan best suits each recipient. 

"Original Medicare," managed by the federal government, has two parts: Part A (hospital insurance) and Part B (medical insurance). Medicare Part C, also known as Medicare Advantage, bundles the benefits of Original Medicare together under a plan provided by a private insurance company.

A Medicare Advantage plan also typically includes prescription drug coverage, which Original Medicare members must apply for separately. Medicare Advantage plan costs and other specifics vary, and they may offer additional benefits that Original Medicare does not, such as medical transportation and dental care. Over 50% of people enrolled in Medicare as of January 2025 were members of Medicare Advantage or other plans.

 

Medicare Part C combines both parts of Original Medicare — Part A and Part B — into a single plan. 

A primary difference between Original Medicare and Medicare Part C relates to their public vs. private oversight — the federal government manages Original Medicare, while Medicare Advantage plans are sold by private insurance companies, causing premiums to vary based on your location, plan, and benefits. 

 

Part C may also have lower out-of-pocket costs than Original Medicare because insurance companies can set their own copays, deductibles, and annual out-of-pocket limits. For example, your copay when you see a doctor may be less than the 20% coinsurance amount you'd pay under Original Medicare.

Insurance companies that offer Medicare Part C plans must follow the rules established by the Centers for Medicare and Medicaid Services. Every Medicare Advantage plan must provide at least the same level of coverage as Original Medicare, but insurers may cover additional services to make their plans more appealing. 

For example, Original Medicare doesn't pay for routine dental and vision care, but some Medicare Part C plans cover eye exams, routine dental cleanings, and dentures. Most Medicare Advantage plans also include prescription drug coverage. People with Original Medicare Part A and B must enroll in separate Part D drug plans for prescription drug coverage.

There are several different types of Medicare Advantage coverage options. Plans vary based on physician choice and the services they provide. The plans also differ in price structure and requirements. Explore various providers in the following section.

Unless you choose a point-of-service plan with a health maintenance organization (HMO), you typically must receive medical care from providers in the HMO network. An HMO plan covers out-of-network services for emergency medical care, out-of-area dialysis, and out-of-area urgent care. Otherwise, the HMO may not cover costs if you visit a provider outside of the plan's network.

HMOs have a few other restrictions in place to keep costs down. For example, if you select a Medicare Part C HMO plan, you'll most likely need to choose a general practitioner who manages your medical care, known as a primary care provider (PCP). You'll also need to ask your PCP for a referral to see a specialist. Follow all the rules regarding referrals and prior approvals for medical services to minimize your out-of-pocket expenses on an HMO plan.

Preferred provider organizations (PPOs) offer more flexibility than HMO plans. Although seeing a preferred provider is less expensive, you can usually go to any doctor or hospital to receive covered services, even beyond your network.

In most cases, you don't need referrals for specialists, although choosing a specialist within the plan's network can help you save money. PPO plans do not require you to choose a PCP, giving you more freedom when managing your health.

A private fee-for-service (PFFS) Medicare Part C plan pays providers a predetermined amount for each service. If you enroll in a plan with a PFFS network, you can reduce your out-of-pocket expenses by seeing providers in the network.

You can also see an out-of-network provider, but it usually costs more to do so. Nonnetwork providers must also agree to treat you and accept the reimbursement offered by your plan. There's no need to choose a PCP or request a referral to see a specialist, making PFFS plans more flexible than HMO plans.

Special needs plans (SNPs) are ideal for people who qualify for both Medicare and Medicaid, have a severe chronic illness, and/or reside in the community but need facility-level medical care.

SNPs may offer additional benefits like longer hospital stays for members with severe conditions. Each SNP coordinates members' care to meet their unique needs.

If you qualify for an SNP, you may need to receive care from providers within the SNP network, except if you need emergency care, urgent care, out-of-area dialysis, or end-stage renal disease services. You may also be required to choose a PCP or ask for referrals for many services.

Medical savings accounts (MSAs) are similar to the health savings accounts (HSAs) offered by many employers but operate within Medicare Part C. With an MSA, you get a high-deductible Medicare plan that doesn't start paying for your medical care until you meet the annual deductible.

You can receive care from any Medicare-approved health care professional and do not need to select a primary care provider or get a referral to see a specialist. However, unlike other types of  Medicare Part C plans, MSAs don't include prescription coverage.

Medicare Part C is known as an all-in-one version of Medicare. Unlike Original Medicare, which separates inpatient and outpatient care, Medicare Part C bundles hospital insurance and medical insurance together, giving you coverage for a wide range of medical services and supplies. 

 

Most Medicare Part C plans also include prescription coverage, which isn't included in Original Medicare. Your Medicare Part C provider may even cover extra services not covered by Original Medicare, such as transportation to medical appointments. 

Because Medicare Part C combines hospital insurance, medical insurance, prescription coverage (in most cases), and extra services in one plan, it covers many of the services and medical supplies you'll need to stay healthy and address any acute or chronic health problems, including the following:

• Lab tests
• X-rays
• Surgery
• Immunizations
• Preventive screenings
• Doctor visits
• Durable medical equipment
• Cardiac rehabilitation
• Emergency care
• Splints and casts
• Prosthetic devices

In addition to hospital care, preventive care, and treatments for illnesses and injuries,  Medicare Part C covers several types of senior care.

Medicare Part C does not cover custodial care or assistance with the activities of daily living that someone can provide without any professional training. Providers consider most care in settings like assisted living facilities as custodial care and therefore not covered by Medicare. 

However, Medicare may cover skilled nursing care received in nursing homes or memory care facilities on a short-term basis. For Medicare Advantage to pay for your stay in a nursing home or other skilled nursing facility (SNF), you must have a qualifying hospital stay, and a doctor must confirm that you require daily skilled care. 

Only nurses, therapists, and other individuals with professional training can provide skilled care. You must also receive skilled care in a Medicare-certified SNF to use your Medicare Part C benefits to cover your stay.

Medicare Part C may cover the following services during a stay at an SNF, if the services are deemed medically necessary:

• Physical and occupational therapy
• Health-related social services
• Ambulance transportation
• Speech-language pathology services
• Services provided by a registered dietitian
• Medications

Medicare Part C pays for home health services to help you preserve your independence and stay in your own home as long as possible. If you have a chronic disease, you may need home health care services to monitor your progress on a new treatment plan or make sure that your condition is as stable as possible. 

Medicare Part C also pays for physical therapy, occupational therapy, wound care, health-related education, and injections. However, a Medicare Advantage plan will not typically cover nonmedical in-home services, often called in-home care or "home care." This lack of coverage is because in-home care differs from home health care and is considered not medically necessary. 

To qualify for home health care under Medicare Part C, you must be homebound and have a physician's order for skilled care. Coverage is limited to part-time or intermittent skilled services.

Medicare covers hospice care as part of Medicare Part C plans. To qualify for this level of care, your doctor must certify that you have a life expectancy of no more than six months. 

Medicare covers hospice care under Original Medicare even for beneficiaries enrolled in Medicare Part C. When a person receives hospice care, Medicare part C coordinates with Original Medicare to provide these services. The Medicare part C Plan will help an individual locate a Medicare-approved hospice provider in their area.

When seeking hospice under Medicare, you must also sign a document acknowledging that you want hospice care rather than services intended to treat the illness. If you qualify for hospice care under Original Medicare guidelines, your plan will cover medications, nursing care, durable medical equipment, and other services. You may be able to receive hospice care at home or a long-term senior living facility.

To qualify for Medicare, you must be at least 65 years old or have a qualifying disability. For most disabilities, you need to receive disability benefits for 24 months before you qualify for Medicare. However, you can qualify sooner if you have amyotrophic lateral sclerosis (Lou Gehrig's disease) or end-stage renal disease requiring dialysis or a kidney transplant.

You must also be a U.S. citizen or a lawful permanent resident of the United States. If you're a lawful permanent resident, you must have lived in the United States for at least five consecutive years. Finally, you must be enrolled in Medicare Part A and Medicare Part B to qualify for a  Medicare Part C plan.

To summarize, you must meet the following requirements to enroll in Medicare Part C:

• U.S. citizen or lawful permanent resident
• At least 65 years old or have a qualifying disability
• Enrolled in Medicare Part A and Medicare Part B

The initial enrollment period begins three months before you first sign up for Medicare Part A and/or Part B and ends three months after. If you do not enroll during this period, you may join a Medicare Part C plan during the Open Enrollment Period from Oct. 15-Dec. 7.

Individuals may also be able to sign up for a Medicare Advantage plan during a "Special Enrollment Period" if they have a qualifying life event. Examples include a move to a new location or becoming eligible for Medicaid. The dates for this enrollment period vary.    

During an initial, open, or special enrollment period, sign up for Medicare Part C with the following steps:

• Create a Medicare website account and visit the Medicare plan comparison page to view available Medicare Advantage plans.
• Reference the "Medicare & You" handbook to compare plans listed at the back of this resource.

• Selecting "Enroll" for the plan on the Medicare plan comparison page.
• Contact plan representatives via the phone or online. You can also request a form and mail it in to them. 
• Call Medicare representatives at 1-800-633-4227.

When selecting the best Medicare Advantage plan, consider each option's rules and guidelines. Determine if you will have access to your preferred doctors, specialists, health care facilities, and coverage levels. Identify additional service coverage options that you may need.  

• Providers and Networks: Some plans won't cover services delivered by out-of-network providers. Others cover out-of-network care at lower rates than in-network care. If a plan doesn't have a large network, you could be forced to use out-of-network doctors and hospitals, increasing your out-of-pocket costs.
• Coverage of Preferences: If you prefer a specific hospital, make sure that it operates within the plan's network — especially if you have a chronic health issue and require specialized care at the facility. 
• Specialist Access: Before enrolling in a Medicare Part C plan, make sure it provides access to various specialists, such as cardiologists, gastroenterologists, nephrologists, and other physicians you might need in the future.
• Extra Services: Medicare Part C often covers additional services that Original Medicare does not. If you need dental care, vision care, hearing aids, or other extra services, check the plan details to make sure it covers the services you need.

Medicare Part C, also known as Medicare Advantage, is an alternative to "Original Medicare" that allows older adults to receive coverage from private providers. Within Medicare Part C, several types of providers can deliver plans. 

Before committing to a plan, seniors should research various providers, coverage options, and services to ensure their needs are adequately met.

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