What Does Medicare Part C (Medicare Advantage) Cover?
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: September 9, 2020
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 covers the inpatient care typically covered by Medicare Part A.
- 4 Medicare Advantage plans must provide at least the same amount of coverage as Original Medicare.
Medicare Part C, also known as Medicare Advantage, is a type of Medicare coverage offered by private insurance companies instead of the federal government. It 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 by 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. Some plans are set up as health maintenance organizations (HMOs), which have networks of doctors and hospitals that have agreed to accept specific payment amounts for each service provided. HMOs typically don’t cover the cost of care provided by a health professional who’s not in the network. Other Part C plans are set up as preferred provider organizations (PPOs). These plans have networks of participating providers, but they usually allow subscribers to use out-of-network doctors or hospitals for an additional fee.
What’s Covered by Medicare Part C?
Medicare Part C covers the inpatient care typically covered by Medicare Part A. If a Medicare Part C subscriber is admitted to the hospital, their 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.
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.
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 supplemental 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 the subscriber needs 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, subscribers have to enroll in a supplemental drug plan or pay out of pocket for their prescriptions. 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.
For subscribers 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 the patient in a semi-private room would endanger his or her health or the health of someone else. For example, if a subscriber has an infectious disease, Medicare Part C will cover a private room to ensure the subscriber remains isolated and prevent the disease from spreading to other patients.
What to Do If Something You Need Isn’t Covered by Medicare Part C
Before paying out of pocket for services that aren’t covered by Medicare Part C, subscribers should explore the possibility of purchasing a Medicare prescription drug plan. This is the best option for subscribers whose Part C plans don’t include prescription coverage. A prescription plan, known as Medicare Part D, covers medically necessary generic and brand-name drugs.
If the non-covered item isn’t a prescription drug, the subscriber may be able to get it covered under a second insurance plan. For example, subscribers who are still working may be able to combine their Medicare Part C coverage with the coverage provided under an employer-sponsored health insurance plan. For subscribers with private insurance, the private plan usually pays first if the employer has at least 20 employees. Once the private plan processes the claim, a second claim is submitted to the Medicare Advantage insurer. Anything not covered by either plan must be paid out of pocket by the subscriber.
How Do I Sign Up for Medicare Part C?
To join a Medicare Advantage (Medicare Part C) plan, the subscriber 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. A subscriber must also live in the service area covered by the plan.
Other stipulations may determine who qualifies for Medicare Advantage plans. For example, they aren’t typically available to people with end-stage kidney disease, except under certain circumstances.
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 to receive coverage under Medicare Part C.
- Sources [-]
https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-c/index.html Last accessed April 2021
https://www.medicare.gov/coverage/inpatient-hospital-care Last accessed April 2021
https://www.medicare.gov/what-medicare-covers/what-part-b-covers Last accessed April 2021
https://www.medicare.gov/Pubs/pdf/10110-Medicare-Preventive-Services.pdf Last accessed April 2021
https://www.medicare.gov/drug-coverage-part-d/what-medicare-part-d-drug-plans-cover Last accessed April 2021
https://www.medicare.gov/coverage/dental-services Last accessed April 2021
https://www.medicare.gov/coverage/eye-exams-routine Last accessed April 2021
https://secure.ssa.gov/apps10/poms.nsf/lnx/0600601015 Last accessed April 2021
https://www.medicare.gov/supplements-other-insurance/how-medicare-works-with-other-insurance Last accessed April 2021
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html#:~:text=Generally%2C%20Medicare%20is%20available%20for,Part%20B%20(Medicare%20Insurance). Last accessed April 2021
https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf Last accessed April 2021
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.
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.