Medicare Part C

Medicare Part C is optional and referred to as Medicare Advantage. It is essentially a way of receiving Part A and B benefits through a private insurance company.

Medicare Advantage is a bundle of Part A, B, and often D coverage. Plans that include prescription drug coverage are called Medicare Advantage-Prescription Drug plans– MA-PDs.

Part C typically comes with a local network of providers. You will still pay copays for many routine services like doctor’s visits, lab-work, ambulance, surgeries, hospital stays, urgent care and other services. All plans come with a maximum out-of-pocket limit and many plans come with extra benefits.



Coordinated Cost Plans:

Health Maintenance Organization (HMO) Plans:
  •  Use doctors and hospitals within the plan network
  • Out-of-network providers are covered in the case of an emergency
  • The maximum out-of-pocket limit is $6,700
  • Out-of-network coverage is limited (unlike with PPOs)
    • cost-sharing for Point of Service coverage is higher than that under network providers
  • You may ONLY receive Part D coverage through the plan (cannot get a stand-alone PDP)


Preferred Provider Organization (PPO) Plans:
  • Covers any U.S. provider who accepts Medicare
  • Nor referral needed for out-of-network service
  • Higher cost-sharing for out-of-network service
  • The maximum out-of-pocket limit is $6,700, $10,000 limit on the network
  • You may ONLY receive Part D coverage through the plan (cannot get a stand-alone PDP)


Private Fee-for-Service (PFFS) Plan:

  • Covers at any Medicare provider
  • If the plan has a network, you may pay extra for out-of-network providers
  • Must verify that out-of-network providers accept your plan prior to visit
  • Providers cannot charge more than 15% of the Medicare rate
  • The maximum out-of-pocket limit is $6,700
  • Some plans have Part D coverage, or you can also purchase a stand-alone PDP


Medical Savings Account (MSA) Plans:

  • Pay healthcare expenses from a medical savings account, then OOP until your deductible is met– then plan pays for all costs
  • Coverage at all approved providers
  • May no have a network
  • Covers preventative services with no cost-sharing, but you must pay for services
  • This plan does NOT cover part D coverage– you need to purchase a stand-alone PDP with this plan for coverage
  • You must pay the part B premium and a high deductible
  • You may NOT enroll if you:
    • receive benefits that cover the whole deductible
    • are dual-eligible (eligible for both Medicare and Medicaid)
    • already have hospice services
    • are enrolled in Federal Employee Health Benefits
  • You may receive Part D coverage ONLY through a stand-alone PDP


Special Needs Plans (SNPs)

  • Available for people with chronic conditions, dual-eligibility, or who were institutionalized for 90+ days
  • Provides Part D coverage
  • C-SNP:
    • for people with severe, disabling conditions
  • D-SNP:
    • for people who are entitled to both Medicare and Medical Assistance from a State Plan (Medicaid)
  • I-SNP:
    • for people who have spent at least 90 days in long-term care, skilled nursing treatment, an intermediate care facility, or a psychiatric institute


What Does Medicare Part C Cover?

Medicare Part C is required to cover all the benefits from both Part A and Part B. However, rather than paying for 20% of the costs like in Original Medicare, you will pay copay in Part C.

Some items might not have a copay, so you do not need to pay for them. Meanwhile, the highest amount that you might have to pay in the network for any service is 20%. You typically pay 20% coinsurance for things like durable medical equipment, dialysis, chemotherapy, and radiation. Review your summary of benefits carefully to see what you can expect to pay for these and other items.


What Does Medicare Part C Cost?

In addition to a monthly premium, the plan might include a deductible, copays, and coinsurance (up to the plan’s out-of-pocket maximum– typically $6,700). The premiums, copays, benefits, and drug formulary often change from year to year as plans renew their contracts with Medicare.

Some Medicare Part C plans do not have premiums.  This is because Medicare pays a fixed monthly sum to the insurance carrier to provide the coverage.

Out-of-Pocket Maximums

Every Medicare Part C plan must have an out-of-pocket maximum to protect you from extreme medical expenses. Many of the Medicare Part C plans’ OOP is set by Medicare at $6700. This means that once your Part C expenses reach $6700, any costs past this will be covered by the insurance. Everything you spend on Part A and B services counts toward your out-of-pocket maximum. If you hit that maximum, your Part C plan will pay all the costs after that for the rest of the year.

OOP costs are crucial to keep in mind when you are choosing a Medical Advantage plan. You need to consider whether or not you will be able to pay the maximum yourself in case you have high medical costs one year. If the maximum is too high, we can help you find a plan with lower OOP costs or a Medigap plan to bridge your coverage.

Unlike Medicare Advantage, Original Medicare does not have an OOP limit.


Medicare Part C Eligibility

To be eligible for Part C Medicare Advantage, you:

  • Must be enrolled in BOTH Medicare Part A and B
  • Must live in the plan’s service area– plans sometimes cover counties our whole states
  • Do not have End-Stage Renal Disease


Medicare Part C Enrollment Periods

There are specific periods during which you may enroll/disenroll from Medicare Advantage plans.

During your Initial Enrollment Period (when you first get Part B):

  • you can enroll/disenroll from an MA plan or MA-PD plan
  • only one election can be made

During the Annual Election Period  (October 15 – December 7th):

  • you may add/drop an MA plan
  • unlimited elections can be made– the last election will be the effective one

During the Open Election Period  (January 1st – March 31st):

  • you may change your MA or Ma-PD plan
  • only one election can be made

If you are under special circumstances like you just moved or dropped employer health coverage, you may qualify for a Special Enrollment Period. To learn more, visit our page on enrollment periods.