Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
The terms Medicare Part C and Medicare Advantage Plan are interchangeable. Medicare has four different parts: Part C is a bundle that covers Part A, Part B, and usually, Part D.
- Part A (hospital insurance) includes inpatient services such as hospitalization, skilled nursing home care, hospice care, and some home health care.
- Part B (medical insurance) includes outpatient services such as doctor’s visits, ambulance transport, laboratory tests, x-rays, and preventive care.
- Part A + Part B = Original Medicare (also known as Traditional Medicare) is administered by the federal government.
- Part C (“MA” or Medicare Advantage) bundles Part A, Part B, and usually Part D services together in one plan. Part C is an alternative way to receive your Medicare benefits. Once you are enrolled in Part A and Part B, you can choose to receive your benefits through Original Medicare or a Medicare Advantage Plan.
- Part D (prescription drug coverage) helps pay for prescription drugs. You can join a Part D prescription drug plan (PDP) if you have Original Medicare. Most Medicare Advantage Plans include prescription drug coverage, so you don’t have to join a separate drug plan.
- Part C and Part D are administered by Medicare-approved private insurance companies and are regulated by the federal government.
What Does Medicare Part C Cover for Inpatient Care?
Medicare Part C generally provides the same inpatient benefits as Medicare Part A. These include:
- Inpatient hospital care if you have a doctor’s order and the hospital is in your plan’s network. Depending on your plan’s rules about how you obtain inpatient benefits, you may need a referral and prior authorization. Hospital care may be for acute illness or injury, rehabilitation, long-term care, or mental health.
- Cost-sharing (how much your plan pays and how much you pay) is structured differently with a Medicare Advantage Plan. Original Medicare Part A charges a deductible ($1,556 in 2022) for each benefit period. Medicare Advantage Plans typically charge a copay (ranging from $170 to $225) for the first several days of an inpatient stay. If you stay longer, your copay is $0. A transfer from one type of inpatient facility to another is considered a new admission and initial copays apply.
- Skilled nursing facility care and rehabilitation services provided on a continuous, daily basis in an in-network skilled nursing facility (SNF). Services are paid for in accordance with Medicare guidelines.
When you receive services in an inpatient setting, your Medicare Advantage Plan covers medically necessary care in accordance with Medicare guidelines and your plan’s rules. These services typically include:
- A semi-private room (unless a private room is necessary)
- Physician’s services
- Diagnostic procedures
- Physical, occupational, and speech therapy
- Medical supplies
What Does Medicare Part C Cover For Outpatient Care?
Medicare Part C generally covers the same outpatient benefits as Medicare Part B that you receive in an outpatient setting in your plan’s network. Prior authorizations and referrals may apply. Outpatient care includes:
- Diagnostic tests and therapeutic services and supplies, such as x-rays, casts, blood, and lab tests that are received in an outpatient setting
- Outpatient hospital services, such as observation, surgical procedures, emergency care, partial hospitalization for mental health, infusion therapy, and certain screening and preventive services
- Outpatient mental health care, such as individual or group therapy
- Outpatient rehabilitation services, such as physical, occupation, or speech therapy provided in a variety of outpatient settings
- Outpatient substance abuse services, such as individual or group therapy
- Outpatient surgery or other services provided at a hospital outpatient facility or ambulatory surgical center
As with inpatient services, you must follow your plan’s rules outlined in your Evidence of Coverage document. Cost-sharing is typically structured differently as well. For instance, you may pay a deductible before your plan starts to pay, but most Medicare Advantage Plan carriers offer zero-deductible plans. You may be responsible for copays or coinsurance when you receive services.
Does Medicare Part C Cover Prescription Drugs?
According to the Kaiser Family Foundation, 89% of Medicare Advantage Plans include prescription drug coverage in 2022. Most of these plans are Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). In fact, if you join an HMO or PPO, you will not be able to purchase a standalone Medicare Part D prescription drug plan (PDP).
Part C plans with prescription drug coverage must follow Medicare’s rules but may have different formularies (drug lists) and preferred pharmacies. Your out-of-pocket costs for drugs do not apply toward your maximum out-of-pocket limit.
What Are The Additional Benefits Of Medicare Part C Coverage?
Part C plans can offer additional benefits beyond what Original Medicare offers. Medicare Advantage Plans can use rebate dollars paid by Medicare to cover the costs of these benefits (except telehealth). The scope and breadth of these benefits vary depending on your plan, but over 90% of Medicare Advantage Plans in 2022 include some coverage for:
- Eye exams and/or corrective lenses
- Hearing exams and/or aids
More than two-thirds of Medicare Advantage Plans in 2022 offer these additional benefits as well:
- Allowance for over-the-counter medications
- Remote access technology
Other less common additional benefits include:
- In-home support
To access any of these additional benefits, you must follow your plan’s rules, including using network providers and obtaining referrals and prior authorizations. Copays may apply. Beyond routine eye, dental, and hearing exams, most Medicare Advantage Plans provide an allowance for some benefits. For instance, you may receive $150 toward the purchase of eyeglasses if you use an in-network provider. Your benefits and how much you pay are detailed in your plan’s Evidence of Coverage document.
These additional benefits are not covered by Medicare but are offered as non-covered services by your Medicare Advantage Plan. Your out-of-pocket costs, such as copays, do not apply toward your maximum out-of-pocket spending limit.
Learn More From Our Sources
- KFF | 2022 Medicare Advantage Spotlight: First Look | Last accessed October 2022
- Medicare | Medicare Advantage Plans Cover All Medicare Services | Last accessed October 2022
- Medicare | Medicare Advantage Plans | Last accessed October 2022
- Medicare | Drug Coverage (Part D) | Last accessed October 2022
- Medicare | What Part A Covers | Last accessed October 2022
- Medicare | Things to Know About Medicare Advantage Plans | Last accessed October 2022
- Medicare | Evidence of Coverage | Last accessed October 2022
- Medicare | What Part B Covers | Last accessed October 2022