Medicare Part C Explained

Medicare Advantage Made Simple

Medicare Part C is more commonly called Medicare Advantage. It is another way to receive your Medicare coverage instead of using Original Medicare by itself.

A Medicare Advantage plan is offered by a private insurance company approved by Medicare. To join a Medicare Advantage plan, you must have both Medicare Part A and Medicare Part B. Medicare Advantage plans are sometimes called “Part C” or “MA plans,” and most include Medicare drug coverage, also known as Part D.

Our goal is to help you understand what Medicare Part C is, how it works, how it differs from Original Medicare, and what questions to ask before choosing how you want to receive your Medicare coverage.

This page is educational only. We do not recommend any specific plan, carrier, premium, or plan benefit.

What Is Medicare Part C?

Medicare Part C, or Medicare Advantage, is an alternative way to receive your Medicare benefits.

Instead of getting your Medicare coverage directly through Original Medicare, you receive your Medicare-covered services through a Medicare-approved private insurance company. Medicare Advantage bundles your Part A, Part B, and usually Part D coverage into one plan.

A simple way to remember it:

Medicare Advantage is another way to receive your Medicare benefits through a private insurance company approved by Medicare.

Medicare Advantage does not replace Medicare. You are still in the Medicare program, and you still must have Medicare Part A and Part B to join a Medicare Advantage plan.

Medicare Advantage vs. Original Medicare

Most people receive Medicare coverage in one of two main ways: Original Medicare or Medicare Advantage.

Original Medicare

Original Medicare includes Medicare Part A and Medicare Part B. With Original Medicare, you can generally use any doctor or hospital that accepts Medicare anywhere in the United States. You may also choose to add a separate Medicare Part D prescription drug plan and may choose to buy Medicare Supplement Insurance, also called Medigap, to help lower your share of certain costs.

Medicare Advantage

Medicare Advantage is Part C. It is offered by private insurance companies approved by Medicare. It provides another way to receive your Part A and Part B benefits, and most Medicare Advantage plans include prescription drug coverage.

A simple way to think about the difference:

Original Medicare is the traditional way to receive Medicare. Medicare Advantage is an alternative way to receive your Medicare benefits through a Medicare-approved private insurance company.

This page is not here to tell you which one is better. The right path depends on your situation, your healthcare needs, your doctors, your prescriptions, your budget, and your preferences.

Do You Still Have Medicare With Part C?

Yes.

If you join a Medicare Advantage plan, you are still in the Medicare program. Medicare Advantage is simply another way to receive your Medicare benefits.

This is an important point because many people hear the phrase “private insurance company” and wonder if they are leaving Medicare. You are not leaving Medicare. You are choosing to receive your Medicare benefits through a Medicare-approved private plan.

You must have both Part A and Part B to join a Medicare Advantage plan.

Do You Still Pay for Part B?

Yes, in most cases, you continue to pay your Medicare Part B premium if you join a Medicare Advantage plan.

Your Medicare Advantage carrier, may charge a premium in addition to the monthly Part B premium, depending on the plan.

A simple way to remember it:

Medicare Advantage does not make Part B go away. You still need Part A and Part B to join.

Plan costs can vary, so it is important to review premiums, deductibles, copayments, coinsurance, and estimated yearly costs before making a decision.

Medicare Advantage and Doctor Networks

One of the biggest differences between Original Medicare and Medicare Advantage is how provider access works.

With Original Medicare, you can generally use any doctor or hospital that accepts Medicare anywhere in the United States.

With Medicare Advantage, you may need to use doctors, hospitals, and other providers in the plan’s network and service area for non-emergency care. Some plans may offer out-of-network coverage for certain non-emergency services, but typically at a higher cost.

Before joining a Medicare Advantage plan, it is important to ask:

• Are my doctors in the plan’s network?

• Are my preferred hospitals in the network?

• Are my pharmacies in the network?

• What happens if I travel or spend part of the year in another state?

• Do I need referrals to see specialists?

These are practical questions that can make a major difference in how the coverage works for you.

Medicare Advantage and Referrals

Some Medicare Advantage plans may require referrals before you see certain specialists.

With Original Medicare, in most cases you do not need a referral to see a specialist, while with Medicare Advantage, you may need to get a referral.

This does not mean one option is automatically better than the other. It simply means the rules can work differently.

If you regularly see specialists, this is something to understand before choosing a Medicare Advantage plan.

Medicare Advantage and Prior Authorization

Some Medicare Advantage plans may require approval before they cover certain services or supplies. This is called prior authorization.

In most cases, Original Medicare does not require approval before covering services or supplies, while Medicare Advantage plans may require approval before certain services or supplies are covered.

Prior authorization is one of the most important terms to understand because it can affect how and when certain care is approved.

A good question to ask is: “Which services may require prior authorization under this plan?”

Medicare Advantage and Prescription Drug Coverage

Most Medicare Advantage plans include Medicare drug coverage, also known as Part D. Most Medicare Advantage plans include Part D, which means people in those plans generally do not need to join a separate Medicare drug plan.

However, prescription coverage can vary by plan.

Before choosing a plan, it is important to check whether your medications are covered, what your costs may be, and whether your preferred pharmacy is in the plan’s network.

Medicare Advantage vs. Medigap

Medicare Supplement Insurance, also called Medigap, works with Original Medicare.

It does not work the same way with Medicare Advantage. It is important to note that you cannot buy Medigap to cover your out-of-pocket costs if you have Medicare Advantage.

This is one of the most important distinctions to understand.

A simple way to remember it:

Medigap works with Original Medicare. Medicare Advantage is a different way to receive your Medicare coverage.

In most cases, people are choosing between an Original Medicare pathway and a Medicare Advantage pathway.

Medicare Advantage Costs

Medicare Advantage costs vary by plan.

Depending on the plan, costs may include:

• Your Medicare Part B premium

• A Medicare Advantage plan premium, if the plan has one

• Deductibles

• Copayments

• Coinsurance

• Prescription drug costs, if drug coverage is included

• Different costs for in-network and out-of-network care

Out-of-pocket costs vary in Medicare Advantage and plans may have different costs for certain services. Medicare Advantage plans also have a yearly limit on what you pay for covered Medicare services, which may include different limits for in-network and out-of-network services.

This out-of-pocket limit is one of the major structural differences between Medicare Advantage and Original Medicare.

Medicare Advantage Service Areas

Medicare Advantage plan availability depends on where you live.

Insurance companies can decide whether to offer a plan statewide or only in certain counties. They can also decide to offer more than one plan in an area, and plan availability can change from year to year.

This is why Medicare Advantage is usually researched by ZIP code or county.

A plan that is available in one area may not be available in another area.

When Can You Join a Medicare Advantage Plan?

You can only join, switch, or drop a Medicare Advantage plan, another Medicare health plan, or a Medicare drug plan during certain enrollment periods.

Common Medicare Advantage enrollment periods include:

• Initial Enrollment Period

• Annual Open Enrollment Period

• Medicare Advantage Open Enrollment Period

• Special Enrollment Periods

The timing can depend on your situation, so it is important to understand the enrollment rules before making changes.

What to Check Before Choosing Medicare Advantage

Because Medicare Advantage plans vary, you should look beyond the name of the plan and understand how the coverage works.

Before choosing a Medicare Advantage plan, consider asking:

• Do I have both Medicare Part A and Part B?

• Is this plan available where I live?

• Are my doctors in the network?

• Are my hospitals in the network?

• Are my prescriptions covered?

• What are my estimated yearly costs?

• Are referrals required?

• Are there prior authorization rules?

• What happens if I travel or live in another state part of the year?

• How does this plan handle emergency and urgent care?

Common Misunderstandings About Medicare Advantage

“Medicare Advantage is the same as Original Medicare.”

Medicare Advantage plans must cover almost all medically necessary services Original Medicare covers, but they can have different rules, networks, costs, and authorization requirements.

“If I join Medicare Advantage, I no longer need Part B.”

Not correct. You must have both Part A and Part B to join a Medicare Advantage plan.

“I can use Medigap with Medicare Advantage.”

Incorrect. Medigap works with Original Medicare. You cannot have both a Medigap and Medicare Advantage plan.

“All Medicare Advantage plans work the same way.”

No. Plans can differ by service area, provider network, costs, prescription drug coverage, referrals, prior authorization, and other rules.

The Simple Takeaway

Medicare Part C, also called Medicare Advantage, is an alternative way to receive your Medicare benefits through a private insurance company approved by Medicare.

You must have Medicare Part A and Part B to join. Most Medicare Advantage plans include prescription drug coverage. Plans may have networks, service areas, referrals, prior authorization rules, and different out-of-pocket costs.

The right choice to receive your Medicare coverage depends on your personal situation.

Need Help Understanding Medicare Advantage?

Medicare Advantage can be confusing because plan rules, provider networks, prescription coverage, and costs can vary.

If you are trying to understand how Medicare Advantage compares with Original Medicare, Medigap, or Part D prescription drug coverage, we can help connect you with a licensed Medicare professional who can answer questions based on your situation.

Get Medicare help when you are ready.