What Does Medicare Part C (Medicare Advantage) Cover?

checkmark Fact checkedContributing expert: Roseann Birch, insurance consultant; Reviewed by: Leron Moore, Medicare consultant - Updated: Nov 02, 2021

 

Learn about what Medicare Part C (Medicare Advantage) covers and how you sign up for a plan as an alternative to Original Medicare.

What You Should Know

  • 1 At a minimum, Medicare Part C plans pay for the inpatient services normally covered by Part A, and the outpatient services covered under Part B.
  • 2 Medicare Advantage (Part C) plans are only offered by insurance companies that have been approved by Medicare.
  • 3 Medicare Part C plans typically include prescription drug coverage (Part D) and additional benefits like routine hearing, vision, and dental exams.
  • 4 If you are eligible for Medicare and are enrolled in Part A and B, you can join a Medicare Advantage plan.

Medicare Part C, also known as Medicare Advantage, is the alternative way to get your Medicare health coverage. Instead of Original Medicare which is administered by the federal government, Medicare Advantage (MA) is offered by insurance companies.

MA combines the services covered under Medicare Parts A and B into a single plan. At a minimum, Medicare Part C plans pay for the inpatient services normally covered by Part A, and the outpatient services covered under Part B. A Medicare Advantage Plan may also cover services that aren’t included in Original Medicare, such as preventive dental care or vision exams for glasses.

Medicare Advantage (Part C) plans are only offered by insurance companies that have been approved by Medicare. There are different types of Medicare Advantage Plans, including health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

What’s Covered by Medicare Part C?

Inpatient Care

Medicare Part C covers the inpatient care typically covered by Medicare Part A. If you are a Medicare Part C subscriber and are admitted to the hospital, your Medicare Advantage plan must cover a semi-private room, general nursing care, meals, hospital supplies, and medications administered as part of inpatient care.

Because private insurers provide Medicare Part C plans, it’s up to the insurance company to decide whether the plan offers coverage beyond what Original Medicare would provide. Inpatient care may be covered at acute care hospitals, inpatient psychiatric hospitals, long-term care hospitals, and inpatient rehabilitation facilities.

Outpatient Care

Medicare Advantage Plans must cover the same outpatient services as Medicare Part B, including medically necessary and preventive services. Medically necessary services are the services or supplies needed to diagnose or treat an acute illness, chronic disease, or injury. Medicare Part C also covers things like ambulance services, mental health treatment, clinical research, and certain prescription drugs purchased on an outpatient basis. 

Preventive services are those that help prevent or diagnose illnesses as early as possible, such as mammograms for women over 40 and prostate cancer screening for men over 50. Immunizations for influenza, pneumonia, and hepatitis B are also considered preventive services. 

Prescription Drugs

One of the advantages of enrolling in Medicare Part C is that many plans offer prescription coverage in addition to coverage for inpatient and outpatient care. With Original Medicare, most prescriptions aren’t covered, which means beneficiaries must purchase a prescription drug plan known as Medicare Part D.

Plans with prescription coverage usually have a formulary or a list of all the generic and brand-name drugs covered under the plan. Insurers may also separate these medications into tiers, with drugs in lower tiers having lower copayments than those assigned to the highest tiers. Some plans also have a specialty tier for the most expensive prescriptions.

Dental, Vision, and Other Extra Benefits

Another advantage of enrolling in Medicare Part C is that many plans cover dental and vision services, which aren’t covered by Original Medicare. Depending on the plan selected, Medicare Part C may cover fillings, tooth extractions, cleanings, dentures, and other dental services. Covered vision services may include eye exams, glasses, or contact lenses. Some plans also cover hearing aids, or the exams needed to ensure hearing aids fit properly. Each plan has its own rules for determining what’s covered and whether you need a referral before receiving covered services.

What Isn’t Covered by Medicare Part C?

Medicare Advantage plans must provide at least the same amount of coverage as Original Medicare. Once a plan meets the minimum requirements, it’s up to the insurer to determine if additional services are covered. 

Depending on the plan selected, Medicare Part C may not cover prescription medications. If it doesn’t, you must have other prescription drug coverage. If you have a HMO or PPO, you are not allowed to purchase a separate Part D prescription drug plan.  Although insurers are allowed to cover more services than Original Medicare does, not all Part C plans pay for routine dental care, hearing aids, or routine vision care.

If you are in need of inpatient care, Medicare Part C may not cover the cost of a private room, unless it’s deemed medically necessary. A private room is medically necessary if putting you in a semi-private room would endanger your health or the health of someone else. For example, if you have an infectious disease, Medicare Part C will cover a private room to ensure you remain isolated and prevent the disease from spreading to other patients.

What to Do If Something You Need Isn’t Covered by Medicare Part C

If you do not have other prescription drug coverage, join an HMO or PPO that includes it. You cannot have a separate drug plan and an HMO or PPO at the same time. You can only purchase a separate drug plan if you are enrolled in a Part C plan that doesn’t offer drug coverage, such as a PFFS or MSA. 

You may be able to get other coverage under a second insurance plan. For example, if you are still working, you may be able to combine your Medicare Part C coverage with the coverage provided under an employer-sponsored health insurance plan. If you have private insurance, that plan usually pays first if your employer has at least 20 employees. Once the private plan processes the claim, a second claim is submitted to the Medicare Advantage insurer. You are responsible for any charges not covered by either plan.

How Do I Sign Up for Medicare Part C?

To join a Medicare Advantage (Medicare Part C) plan, you must qualify for Original Medicare, which is available to people aged 65 and older, and younger disabled individuals. Medicare Advantage plans are available to U.S. citizens, U.S. nationals, and other people who are lawfully present in the United States. You must also live in the service area covered by the plan. You must be enrolled in Medicare Part A and B to join a Medicare Advantage (Part C) plan.

For people who meet the eligibility requirements, it’s important to compare Medicare Advantage plans, since coverage and costs vary. You’ll have to enter your ZIP code to find plans in your area. After choosing a plan, it’s necessary to fill out an enrollment form and pay the required premium (Part B plus your plan’s premium) to receive coverage under Medicare Part C.

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.