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Medicare Part C Coverage: What Does It Cover?

Ed McClane
Reviewed by:
Ed McClane

Key Takeaways

  • Medicare Advantage plans (also called Medicare Part C) provide the same coverage as Original Medicare and often include additional benefits like dental, hearing, vision, and prescription drug coverage.
  • On most plans, you can make the most of your benefits by seeing in-networkIn-network refers to the doctors, hospitals and other providers that are inside of your provider network. A provider network is a group of providers that have agreed with your health insurance company to treat its customers. healthcare providers.
  • You can enroll in Medicare Advantage during any of the Medicare enrollment periods. If you’re in the Initial Enrollment Period,The Initial Enrollment Period (IEP) is the seven-month period around your 65th birthday when most people are eligible for the first time to enroll in Medicare. you must have joined Part A and Part B before selecting a Medicare Advantage plan.

Are you having trouble choosing the best coverage? Let’s review the Medicare Advantage (Part C) coverage.

What Medicare coverage is right for my specific situation?

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What Does Medicare Part C Cover?

Medicare Advantage (Part C) replaces Original Medicare (Part A & B), but offers the same Part A & B benefits or coverages as Original Medicare. Along with receiving Part A & B benefits, Medicare Part C often bundles your benefits with additional ones like dental, hearing, vision and prescription drug coverage.

When you have Medicare Advantage, your Part C benefits ID card replaces your Medicare ‘Red, White & Blue’ card at every visit.

You can still join a Medicare Advantage plan if you have pre-existing conditionsA pre-existing condition is an illness, injury or other medical condition you had before you enrolled in your health insurance policy. . 

Why Is Medicare Part C Separate?

Medicare Advantage plans are different from Original Medicare, which is administered by the federal government. Medicare Advantage is private insurance that’s required to meet all of Medicare’s regulations. 

With a Medicare Advantage plan, you have Medicare rights and protections, even though private insurance companies manage your benefits. Medicare Advantage plans can offer additional benefits like Part D prescription drug coverage, vision, dental, and hearing.

Still have questions? GoHealth has the answers you need.

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Does Medicare Advantage Require Use of In-Network Services?

Medicare Advantage plans aren’t as flexible as Original Medicare. Many plans require you to see doctors and go to pharmacies in their provider network to get the most from your benefits. Health Maintenance Organization (HMO) plans generally offer narrower networks, while Preferred Provider Organization (PPO) plans are broader.

What are the Different Types of Medicare Part C Plans?

Medicare Advantage (Part C) plans vary on a state-by-state and even a county-by-county basis. Let’s take a look at the two most popular choices:

Preferred Provider Organization (PPO) 

  • All Part C plans have a provider network, but PPO offers more flexibility to visit an out-of-networkOut-of-network refers to doctors, hospitals and other providers that do not have an agreement to treat your health insurance company’s clients. Visiting an out-of-network provider typically means more out-of-pocket costs and less coverage. provider that accepts Medicare. 
  • In-network providers are more affordable.
  • You are not required to choose a primary care doctor.A Primary Care Physician is a doctor that oversees and monitors your medical care under some plan types. PCPs also may be responsible for referrals to specialists.

Health Maintenance Organization (HMO)

  • You must see an in-network provider unless you need emergency care.
  • Choosing a primary care doctor is a requirement.
  • Plans may require a referral or prior authorization to see specialists and for some tests or procedures.

Additional Part C options include:

  • Special Needs Plans (SNPs)
  • Medicare Medical Savings Account (MSA) plans
  • Private Fee-for-Service (PFFS) plans

FAQs

Medicare Advantage plans and Original Medicare don’t cover care outside of the United States. Consider looking at a Medigap policy if you need coverage in other countries. As for traveling state-to-state, Medicare Advantage plans usually don’t cover non-emergency care if you go outside of your plan’s network.
You can have a Medicare Advantage Plan with ESRD if you meet the following criteria: 
  • You develop ESRD after you’ve already enrolled in a Medicare Advantage Plan
  • You no longer have ESRD after treatment
  • You join a Medicare Special Needs Plan (SNP) that covers ESRD
  • Your Medicare Advantage Plan leaves Medicare or no longer provides coverage in your area 
It’s important to note, people with ESRD were allowed to join Medicare Advantage Plans without restrictions starting in January 2021.
The short answer is no. Although Medicare Advantage plans must cover at least the Medicare “Medically-Necessary Services,” Medicare Advantage Plans can charge different deductibles, offer co-payments (for instance $30 per office visit), or various co-insurance terms (such as 20% of the procedure cost). Some Medicare Advantage plans have a limit on how much you can spend in a year.

Find the Medicare Plan that works for you.

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Sources

This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.

Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.