How Does Medicare Part C Coverage Work?
Medicare Part C (Medicare Advantage) bundles your Part A and Part B coverage through a private plan, usually with drug coverage and extra benefits. Here is how it works.
Medicare Part C, better known as Medicare Advantage, is an all-in-one alternative to Original Medicare sold by private insurance companies that contract with the federal government. A Medicare Advantage plan bundles your Part A and Part B coverage into one plan, and most add prescription drug coverage plus extra benefits. Here is how the coverage works and how to decide whether it fits you.
What does Medicare Advantage cover?
Every Medicare Advantage plan must cover everything Original Medicare covers. Medicare Part A is your hospital insurance and Medicare Part B is your medical insurance, so a single plan has to handle both:
- inpatient hospital stays and care in a skilled nursing facility
- outpatient care, doctor visits, lab work, and durable medical equipment
- home health care when you qualify for it
- preventive services and vaccines, which are covered at no cost on most plans
Most plans go further and add extra benefits traditional coverage does not include. Depending on the plan, those can be:
- drug coverage, which is Medicare Part D built into the plan
- dental, vision, and hearing aids
- gym memberships and wellness programs
- over-the-counter allowances and transportation to appointments
What does Medicare Advantage not cover?
Two gaps surprise people.
Hospice care stays with Original Medicare. Even after you join, Part A pays for hospice. Your plan keeps covering everything else.
Long-term custodial care in a nursing home is not covered, by Medicare Advantage or by Original Medicare. If you need help with daily living rather than skilled care, that is paid privately, through long-term care insurance, or through Medicaid once you qualify.
How does prescription drug coverage work?
Most Medicare Advantage plans include drug coverage. Medicare Part D is built into the plan rather than bought separately, and that version is usually called an MA-PD. Each plan publishes a formulary, which is the list of drugs it covers and the tier each one sits in. Two plans with identical premiums can price the same prescription very differently, so check your own medications against the formulary before you enroll.
If you pick a Medicare Advantage plan without drug coverage, you generally cannot add a stand-alone Part D plan alongside it. The exception is a private fee-for-service plan that does not include drug coverage, or a Medical Savings Account plan. In 2026, once your drug spending reaches $2,100 out of pocket, Part D covers the rest for the year (CMS, 2026).
What does Medicare Part C cost?
You keep paying your Part B premium to the government. The standard Part B premium is $202.90/month in 2026, with a deductible of $283/year (CMS, 2026), and higher earners pay more through an IRMAA surcharge. On top of that, the plan may charge its own monthly premium, though many plans charge $0.
The rest of what you pay is cost-sharing: the plan deductible, copays for visits, and coinsurance on some services.
| Cost | Original Medicare | Medicare Advantage |
|---|---|---|
| Part B premium | You pay it | You still pay it |
| Plan premium | None | $0 on many plans |
| Annual out-of-pocket limit | None | Every plan has one |
| Drug coverage | Separate Part D plan | Usually built in |
| Provider choice | Any doctor taking Medicare | Usually the plan network |
That out-of-pocket limit is the real structural difference. Traditional coverage has no cap on out-of-pocket costs, which is why people pair it with a supplement. Every Medicare Advantage plan has one, and the amount varies by plan.
Types of Medicare Advantage plans
There are four main plan types, and the difference between them is how much freedom you have to pick a doctor.
HMO. A health maintenance organization keeps care inside the plan's network. You choose a primary care doctor and usually need a referral to see a specialist. Premiums tend to be lowest here.
PPO. A preferred provider organization lets you go outside the network for a higher share of the cost, and you do not need a referral to see a specialist. In-network care is still cheaper.
PFFS. A private fee-for-service plan lets you use any provider who accepts the plan's payment terms. Fewer of these exist each year.
SNP. Special needs plans are built for a defined group: people with certain chronic conditions such as diabetes or heart failure, people living in an institution, or people who have both Medicare and Medicaid. Benefits and the drug formulary are tailored to that group.
Part C or Original Medicare with a Medigap policy?
This is the decision most people are actually making, and you cannot have both. A Medigap policy, also called Medicare supplement insurance, works only alongside Original Medicare. It pays your share afterward, so you keep any doctor who accepts Medicare and you have no network.
Medicare Advantage takes the other approach: a network and cost-sharing in exchange for a cap on your spending, usually drug coverage, and the extras above, often at a much lower premium.
There is one timing trap worth knowing. Your Medigap open enrollment runs six months from the first month you are both 65 or older and enrolled in Part B. Miss it and an insurer can, in most states, refuse you or charge more based on your health. A few states are more generous: New York and Connecticut do not medically underwrite Medigap at all, and Massachusetts runs its own guaranteed-issue window each year. Medicare Advantage has no health questions at all.
How to join a Medicare Advantage plan
You need Medicare Parts A and B and you must live in the plan's service area. There are three ways in:
- your initial enrollment period, the seven months around your 65th birthday
- the annual open enrollment period, October 15 to December 7
- a special enrollment period if you move, lose other coverage, or qualify another way
There is also the Medicare Advantage open enrollment period, January 1 to March 31, when anyone already in a plan can switch once or return to Original Medicare.
Frequently asked questions
What is Medicare Part C?
It is Medicare Advantage: a plan from a private insurer, approved by Medicare, that combines your Part A and Part B coverage. Most plans build in Medicare Part D drug coverage and add benefits like dental, vision, and hearing.
How much does a Medicare Advantage plan cost?
You keep paying $202.90/month in 2026 to Medicare, plus any plan premium, and many plans charge $0. You then pay copays, coinsurance, and the plan deductible until you reach the plan's annual out-of-pocket limit.
Do I still need Part B if I have a Medicare Advantage plan?
Yes. You must stay enrolled in both Parts A and B and keep paying that premium. Drop it and you lose the plan.
Can I have a Medigap policy with Medicare Advantage?
No. Medicare supplement insurance only works with Original Medicare. If you want that policy you have to stay in traditional coverage.
Do I need a referral to see a specialist?
On an HMO, usually yes. On a PPO, usually no, though staying in-network costs less. Check the plan's rules before you need the appointment.
What happens if my doctor leaves the plan's network?
The plan must notify you. You can usually keep seeing that doctor at the out-of-network rate on a PPO, but on an HMO you generally have to change doctors or wait for the next enrollment window.
Does Medicare Part C cover hearing aids?
Many plans do, and Original Medicare does not. The allowance and the approved suppliers vary a lot between plans, so compare the hearing benefit specifically rather than assuming.
Talk to a licensed Medicare advocate
Choosing between Original Medicare and a Medicare Advantage plan comes down to three things: your doctors, your medications, and how much risk you want to carry. A licensed Medicare advocate can compare the plans in your area against your own situation, at no cost and with no pressure to enroll.