What Does Medicare Advantage (Part C) Cover?

Medicare Advantage (Part C) plans combine coverage for hospital care, doctor visits and other medical services all in one plan. Plans are required by the federal government to provide all the benefits offered by Medicare Parts A and B, except hospice care, which continues to be provided by Part A. Many plans also provide prescription drug coverage and additional benefits like routine dental and eye care.

  • Medicare Advantage plans (Part C) include all the benefits of Part A, including skilled nursing, hospital stays, home health care and associated services.
  • Medicare Advantage plans (Part C) include all the benefits of Part B, including doctor visits, outpatient care, lab and screening tests, and associated services.
  • Most Medicare Advantage plans include prescription drug coverage.
  • Many plans include additional benefits, such as dental, eye care, hearing care, wellness services and a nurse helpline.

What do Medicare Advantage Plans Cost?

With Medicare Advantage plans, the company that offers the plan sets the monthly premium and decides on the cost-sharing amounts. Some plans have a $0 premium. Look at the details of each plan you’re considering to see what your costs could be. All Medicare Advantage plans have a yearly limit on your out-of-pocket costs for covered medical services. This limit can change each year and may vary for different Medicare Advantage plans.

How does cost sharing work with Medicare Advantage plans?

Most Medicare Advantage plans use a combination of deductibles, co-insurance and co-pays to share the costs of your health care services with you. These cost-sharing arrangements will usually apply to all services the plan covers — hospital stays, doctor visits, drug coverage if you have it and so on. Before you choose a plan, make sure it’s a good fit for your budget.

Is there a limit to what I can be asked to pay out-of-pocket?

Yes. Having a limit on your cost sharing is another way that Medicare Advantage plans differ from Original Medicare (Part A and Part B). All Medicare Advantage plans set an annual limit on your out-of-pocket spending (out-of-pocket maximum) for costs like co-pays and deductibles. This provides financial protection for high-cost care such as diabetes or other chronic conditions, as well as catastrophic or medical emergencies. Premiums do not count toward the limit.

Is there a deductible for prescription drug coverage?

Some Medicare Advantage plans have a separate deductible for prescription drug coverage, while others don’t. Look at the specific plan for details. Tip: Your costs will vary from plan to plan. Shop around for a plan that is a good fit for your needs.

Your choice of providers depends on your Medicare Advantage plan

Most Medicare Advantage plans have service areas, which can limit your care to a geographic boundary. All Medicare Advantage plans offer nationwide coverage for ER, urgent care and renal dialysis. With some Medicare Advantage plans you must choose a primary care doctor (PCP) from a network. This doctor will manage your care, including if you need to see a specialist or go to the hospital. This is often called coordinated care.

Some Medicare Advantage plans allow you to get care from any Medicare-eligible provider who accepts the terms, conditions and payment rates of the plan. These plans do not offer coordinated care.

Coordinated care plans

Coordinated care plans are built on the idea of a network of doctors and hospitals working together to provide care. Each plan creates its own network. In most cases, you will pay most or all costs if you see a provider outside of your plan network.

Health Maintenance Organization (HMO) plans

HMO plans require you to use providers in the plan network. Many require you to get a referral from your primary care physician to see a specialist.

Point of Service (POS) plans

A type of HMO plan that allows you to see doctors and hospitals outside the network for some covered services, usually for a higher co-pay or co-insurance.

Preferred Provider Organization (PPO) plans

PPO plans typically don’t require a referral to see a specialist and allow you to see providers outside the network without having to pay the entire cost yourself.

Special Needs Plans (SNPs)

SNPs are designed for people with a range of special needs, including those with chronic diseases, nursing home residents, and people who are eligible for both Medicare and Medicaid.

Medicare Advantage plans without coordinated care

Private Fee-For-Service (PFFS) plans

PFFS plans allow enrollees to see any providers in the U.S. who accept Medicare’s payment terms and conditions.

Medical Savings Account (MSA) plans

MSA plans combine a high-deductible health plan with a special savings account you can use to pay for qualified health care expenses tax-free.

Enrolling in a Medicare Advantage plan

When can I enroll in a Medicare Advantage plan?

Before you can enroll in a Medicare Advantage plan, you must be enrolled in both Medicare Part A and Medicare Part B. You can first enroll in a Medicare Advantage plan during your Initial Enrollment Period, which is a seven month time span that includes the three months before the month you turn 65, your birthday month and the three months after your birthday month. If you don’t enroll in a Medicare Advantage plan during your Initial Enrollment Period, you may have to wait to enroll during the Medicare Annual Enrollment Period, which is October 15 – December 7.

How do I enroll in a Medicare Advantage plan?

Once you are enrolled in both Medicare Part A and Medicare Part B, you can enroll in a Medicare Advantage plan. You need to enroll directly with the private insurance company that offers the plan. Most companies provide options to enroll over the phone, online or through a meeting with an agent. To find out about enrollment and plans in your area, contact the company directly or visit Medicare.gov.

Do I need to enroll each year?

Your plan renews automatically each year as long as you pay the premium and the plan is still available where you live. You don’t have to do anything to continue your coverage, but make sure that the plan is meeting your needs.