Medicare Part C Explained

What is Medicare Part C?

Medicare Part C is another name for Medicare Advantage plans. With Medicare Part C, you receive your Medicare coverage through a private insurance company. Medicare Advantage plans work differently from Supplement plans. They combine your Part A (hospital), Part B (medical), and sometimes Part D (prescription drug) coverage, into one easy-to-use plan. Medicare Advantage also gives you extra benefits and services that Original Medicare doesn’t cover.

How Medicare Part C works

Medicare Part C is an alternative way to get your Medicare benefits through a private insurance company instead of through Original Medicare. This offers a way to coordinate your care and often includes prescription drug coverage and extras, all in one simple plan.

Here’s how it works:

• Enrollment through private insurers: Medicare Advantage plans are offered through private insurance companies that contract with Medicare. When you join a Part C plan, you’re still covered by Medicare, but the plan helps coordinate and provide your care.
• All-in-one plan structure: Most Medicare Advantage plans combine your coverage into one plan. This includes your Part A (hospital insurance), Part B (medical insurance), and often Part D (prescription drug coverage). This means you can have all these benefits together.
• Network-based care and plan rules: Many Part C plans use a network of doctors and hospitals to provide your care. You may be required to choose a primary care physician within the plan’s network. If you go outside the network for non-emergency care, you may pay more or the care may not be covered. Each plan has its own rules for prior authorization, copays, coinsurance, and out-of-pocket limits, so it’s important to review your options.
• Extra benefits: Many Medicare Advantage plans include additional benefits not covered by Original Medicare. This often includes dental, vision, hearing, fitness programs, wellness programs, an allowance for over-the-counter products, and often Part D prescription drug coverage.

Do I need Medicare Part C?

Enrolling in a Medicare Part C plan offers many benefits that can make it an appealing option for Medicare members. First, Part C provides all-in-one coverage by combining Part A (hospital), Part B (medical), and often Part D (prescription drugs) into a single plan. This simplifies coverage and allows you to manage your care with one plan. Second, Medicare Part C, or Medicare Advantage plans, often include many important benefits not covered by Original Medicare, such as dental, vision, and hearing coverage; wellness programs, and transportation services. Medicare Advantage plans may also help you save money by protecting against unexpected costs because they have a maximum out-of-pocket cost that limits your yearly spending on health care.

The choice to enroll in a Part C plan is up to the individual. A good decision factors in things like preferred providers, health needs, budget, and desired coverage options. For example, enrolling in a Medicare Advantage plan might make sense for someone looking for coverage with added benefits like dental and vision care. It can also benefit someone looking to manage all their Medicare services with one plan rather than having three separate plans for hospital, doctor, and prescription drug coverage. 

What does Medicare Part C cover?

Medicare Part C coverage includes:  

• All services that Medicare Part A and Part B cover.
• Additional benefits and services that Original Medicare does not cover, which can include:
  • Routine hearing, dental, and vision exams.
  • Hearing aids or glasses (except for glasses following cataract surgery).
  • Emergency medical assistance while traveling outside the U.S.
  • Fitness memberships.
  • An allowance to buy health care products.
  • Prescription drug coverage (with some plans).

Medicare Part C vs. Original Medicare

Deciding between Medicare Advantage and Original Medicare is an important choice when you become eligible for Medicare. The table below highlights some of the key differences to help you compare and choose what’s best for your health and budget needs.

Types of Medicare Advantage plans

Health maintenance organization (HMO) plans: 

HMO plans use a network of participating doctors and hospitals for your care and coverage. They may require referrals to see specialists. They often, but not always, include prescription drug coverage.

Preferred provider organization (PPO) plans:

PPO plans offer coverage for services received both in and out of the plan’s provider network. Prescription drug coverage is often included, but not always.

Special Needs Plans (SNP):

Special Needs Plans are designed for people with specific diseases or chronic illnesses, nursing care facility needs, or dual eligibility for Medicare and Medicaid. They often have a network of providers that specialize in the member’s specific condition. Prescription drug coverage must be included.

Private fee-for-service (PFFS) plans:

PFFS plans allow you to see any Medicare participating doctor or hospital that accepts the plan’s payment terms. However, they may or may not include a network of providers. They can include prescription drug coverage, but not always. 

Medical savings account (MSA) plans:

MSA plans combine a high-deductible plan with a medical savings account that the plan deposits money into. They allow you to use the money in the account to pay for health care costs before your deductible is met. MSA plans do not include prescription drug coverage, so you would need a separate Part D plan.

How much does Medicare Part C cost?

Because Medicare Advantage (Part C) plans are offered by private insurance companies, costs vary widely by insurer. Medicare Part C costs include:

• Part A and Part B monthly premiums, if applicable.
• Your Medicare Advantage plan (Part C) monthly premium, if applicable.
• Any out-of-pocket costs such as copays, deductibles, and coinsurance (these costs vary according to your chosen plan).

The average premium for Medicare Advantage (Part C) can vary based on the plan you choose, your location, the insurance provider, coverage options, and additional benefits offered. Plan premiums can range from $0 to $200 depending on the level of coverage and benefits offered. 

Medicare Advantage plans can have lower out-of-pocket costs than Original Medicare.

Is Medicare Part C free?

While some Medicare Advantage (Part C) plans offer $0 premiums or low out-of-pocket costs, they are not entirely free. Some plans have deductibles that must be paid before your plan starts to pay for care. Plans typically have copays or coinsurance for covered services like doctor visits, hospital stays, or prescription drugs. Part D drug coverage is often included in your Medicare Advantage (Part C) plan, but you may have to pay out-of-pocket costs for copays for covered drugs. You may also still have to pay your Part A and Part B monthly premiums, but some plans cover a portion of Part B premiums.

Medicare Part C eligibility

To join a Medicare Advantage (Part C) plan, you must:

• Be a U.S. citizen or lawfully present in the United States.
• Be enrolled in Medicare Parts A and B. Learn when to enroll in Medicare Parts A and B.
• Live for six months or more each year in the plan’s service area.

Why choose UPMC for Life?

UPMC for Life is a Medicare Advantage (Part C) plan that’s been around for 23 years. We are more than 229,000 members strong and growing!

We offer affordable medical and prescription benefits in one easy-to-use plan. We’re committed to providing you with access to the high-quality health care you need so you can live your best life.

Here are just a few benefits you get with UPMC for Life:

• Access to providers you know and trust with more than 60,000 doctors and specialists across PA and out of state. 
• Part D prescription drug coverage with $0 Tier 1 and Tier 2 Rx copays at preferred pharmacies.
• The UPMC for Life Flex Spend Card, which gives you additional dollars to spend on things that help you stay healthy and independent. Use it when you need to for doctor's office copays, fitness, over-the-counter products, and dental, vision, and hearing services.
• Dental allowance for many dental services, including coverage for dentures (on most plans). Plus, oral exams, cleanings, and x-rays.
• A hearing aid exam, a hearing aid fitting, and a great discount on hearing aids.
• A routine vision exam and an allowance for contact lenses and frames, including all lens types, like progressive and transitional.
• FREE unlimited gym memberships, one FREE personal training session each year at participating fitness facilities, the option to work out at home with in-home fitness kits, and online fitness classes.
• In-network coverage when you travel to Arizona, Florida, Georgia, North Carolina, South Carolina, and Tennessee (on HMO plans).
• Benefits and programs that can help you live healthy and stay independent, such as home safety products, in-home safety assessments, Tools for Caregivers, support for serious illness, post-discharge meals, and more.

Frequently asked questions about Medicare Part C

Does Medicare Part C include prescription drugs?

Many Medicare Advantage plans (Part C) include prescription drug coverage (Part D) as part of the plan at no extra cost beyond your plan premium, if applicable. However, not all Part C plans include drug coverage, so it’s important to check whether the plan you’re considering includes Part D benefits.

Can I switch Medicare Part C plans later?

Yes. You can switch Part C plans during specific enrollment periods each year:

• Annual Enrollment Period (Oct. 15 – Dec. 7): This is the best time to make changes for the upcoming year. During this period, you can join or change Medicare Advantage plans, change back to Original Medicare, or add or drop a Part D prescription drug plan. Your coverage will be effective Jan. 1.
• Medicare Advantage Open Enrollment (Jan. 1 – Mar. 31): If you’re already on a Medicare Advantage plan, you can change to another plan or back to Original Medicare. If you choose Original Medicare during this period, you can also join a Part D drug plan. Your coverage will be effective on the 1st of the next month.
• Special Enrollment Periods (SEP): In certain situations, you may qualify to change your plan outside the typical enrollment periods. These include events like moving out of your plan’s service area or losing other health coverage. The rules vary by situation.

It’s always a good idea to review your coverage needs each year to make sure your plan still fits your health care needs and budget.