Medicare Part C

What is Medicare Part C

Medicare Part C, also known as Medicare Advantage (MA), is an alternative way to receive your Medicare benefits. It combines Part A (Hospital Insurance) and Part B (Medical Insurance) into one comprehensive plan offered by private insurance companies approved by the Centers for Medicare & Medicaid Services (CMS).

Most Medicare Advantage plans also include:

Part D (Prescription Drug Coverage).
Extra benefits such as dental, vision, hearing, transportation, fitness, and over-the-counter allowances.

You must be enrolled in both Parts A and B to join a Part C plan, and you continue to pay your Part B premium (plus any additional premium the plan charges).

Table of Contents:

Medicare Part C Cost-Share

Medicare Part C Coverage

Core Medical Coverage

Part C plans are required by law to cover everything that Original Medicare covers, but they may structure copayments and networks differently.

All Part A services, including inpatient hospital, skilled nursing, hospice, and home-health care.
All Part B services, including outpatient visits, preventive care, durable medical equipment, and lab tests.

Prescription Drug Coverage under Part C

If you enroll in a Medicare Advantage plan with drug coverage (MAPD):

You receive your prescription benefits through the same plan that handles your hospital and medical coverage.
All Part D plans must include coverage in each of the following categories and classes:
- Antidepressants.
- Antipsychotics.
- Anticonvulsants.
- Antiretrovirals (HIV/AIDS).
- Immunosuppressants.
- Anticancer drugs not covered by Part B.
The plan must follow Medicare Part D rules and regulations, but it can design its own formularies, cost-sharing tiers, and network pharmacies (within CMS limits).
Your plan will send you a formulary (drug list) and Evidence of Coverage (EOC) explaining how your drug benefits work.

Tier	Type of Drug	What You Pay
Tier 1	Preferred Generics	Lowest copay
Tier 2	Non-preferred Generics	Slightly higher copay
Tier 3	Preferred Brand	Moderate copay
Tier 4	Non-preferred Brand	Higher copay
Tier 5	Specialty Drugs	Percentage coinsurance (usually 25–33%)

Additional Covered Benefits

Most plans offer extra benefits not covered by Original Medicare:

Dental services: routine exams, cleanings, fillings, dentures.
Vision care: exams, lenses, frames.
Hearing: exams and hearing aids.
Fitness programs: SilverSneakers®, gym memberships.
Transportation to medical appointments.
Over-the-Counter (OTC) allowances.
Telehealth and 24-hour nurse lines.
Worldwide emergency coverage.

Medicare Part C Non-Covered Services

Although comprehensive, Medicare Advantage plans may not cover:

Services outside the plan’s provider network (for HMO plans).
Non-medically necessary services.
Experimental or cosmetic procedures.
Certain long-term custodial care.
Unlimited out-of-network access (unless PPO or POS).
Drugs not listed on the plan’s formulary. Medicare Advantage drug coverage cannot include:

Over-the-counter medications, vitamins, or supplements.
Drugs for weight loss or gain.
Cosmetic or fertility drugs.
Erectile dysfunction medications.
Experimental or non-FDA-approved drugs.
Drugs covered under Part B (e.g., infusions, vaccines in clinical settings).

Each plan’s Evidence of Coverage (EOC) details covered and excluded services.

Types of Medicare Advantage Plans (Part C)

Medicare Advantage with Prescription Drugs Plans (MAPD)

Most HMO, HMO-POS, PPO, SNP plans are MAPD (include Part D drug coverage).
Every MA plan sets an annual MOOP (maximum out-of-pocket) for Part A/B services.
Check each plan’s network, referrals, drug formulary, copays, and MOOP before enrolling.

HMO (Health Maintenance Organization)

Uses a network of doctors/hospitals; usually requires a primary care provider (PCP) and referrals to see specialists. No out-of-network coverage except emergencies. Often lowest premiums.

HMO-POS (HMO with Point of Service)

Same as HMO but lets you get some care out-of-network at a higher cost. Still typically needs a PCP/referrals.

PPO (Preferred Provider Organization)

More flexibility: you can see in-network or out-of-network providers (out-of-network costs more). No referral required for specialists.

SNPs (Special Needs Plans)

Tailored benefits/networks:

Chronic Special Needs Plans (C-SNP): For specific chronic conditions (e.g., diabetes, CHF, COPD).
Dual Special Needs Plans (D-SNP): For people with Medicare & Medicaid (dual-eligible).
Institutional Special Needs Plans (I-SNP): For those in nursing homes or needing institutional-level care.

All SNP plans include prescription coverage (Part D). Each type plan are tailored toward specific needs and have unique eligibility requirements, benefits, and enrollment criteria.

PFFS (Private Fee for Service)

Any Medicare-approved provider who accepts the plan’s terms can treat you. May have a limited network; referrals usually not required. Part D may or may not be included.

MSA (Medicare Savings Account)

Combines a high-deductible MA plan with a Medicare-funded savings account you can use for medical costs. No Part D—you must buy a standalone drug plan if you want Rx coverage.

Medicare Advantage Plans without Prescription Durg Coverage

MA only plans are Medicare Advantage plan that covers Part A & Part B services, but no prescription drug coverage. Those plans are good fit for:

VA (Veterans Affairs) individuals.
Employer/retiree group drug plan (EGWP).
Union or other plan that’s deemed creditable by CMS.
Medicare beneficiaries who wants to avoid Part D Late Enrollment Penalty.

Medicare Part C Eligibility

Cost-Share for Home Health Care

You can join a Medicare Advantage plan if:

You are enrolled in both Medicare Parts A and B.
You live in the plan’s service area.
You are a U.S. citizen or lawful permanent resident.

Note: You cannot enroll in a Medicare Advantage plan and a Medigap (Supplement) policy at the same time.

Special programs exist for:

Chronic conditions (C-SNP).
Dual eligibility (Medicare + Medicaid, D-SNP).
Institutionalized or home-based individuals (I-SNP).

Those programs have different eligibility in addition to Medicare Part C eligibility.

Medicare Part C Premium Cost

Medicare Advantage Plans Premium

Medicare Advantage plans may have cost associated with them as follows"

Some insurance carriers may charge plan premium—others may be as low as $0.
You must continue to pay your Part B premium ($185 in 2025).
Part C has no penalty itself, but A, B, and D penalties still apply and may affect your total cost.
If your Part C plan is MA-only (no drugs), there’s no Part D late enrollment penalty and/or IRMAA costs.

Medicare Part C Cost-Share

Medical Services Cost-Sharing

Cost-Sharing for Medicare Advantage plans varies by plan. Typical out-of-pocket expenses include:

Copayments for doctor visits, hospital stays, and prescriptions.
Coinsurance for certain services.
Deductibles (for certain medical services)

Each plan sets an annual Maximum Out-of-Pocket (MOOP) limit on Part A and B costs—once you reach it, the plan pays 100% for covered services.

Prescription Drugs Cost-Sharing

Your prescription drugs cost depends on:

The tier of your medication.
Whether your pharmacy is preferred or standard.
Whether you use mail-order or retail pickup.
Whether you’ve reached the deductible or coverage gap.

Typical cost structure:

$0 – $10 copay for Tier 1 generics.
$30 – $45 for Tier 3 preferred brand drugs.
25% coinsurance for specialty drugs.

Prescription Drugs Coverage Stages (same as Medicare Part D)

MAPD prescription benefits follow the four standard Part D coverage phases, which reset each year.

💊 Medicare Part D Coverage Stages – 2025

Coverage Stage	What It Means	What You Pay (2025)	Ends When...
1️⃣ Deductible Stage	You pay the full cost of your prescriptions until you meet your plan’s annual deductible.	You pay 100% of drug costs until deductible is met (max $590).	When you’ve paid your deductible amount.
2️⃣ Initial Coverage Stage	After meeting your deductible, your plan helps pay for your drugs	You typically pay 25% of covered drug costs (copay or coinsurance), and the plan pays the rest.	When your true out-of-pocket (TrOOP) spending reaches $2,000.
3️⃣ Catastrophic (Out-of-Pocket Cap) Stage	New for 2025: Once you reach $2,000 in out-of-pocket spending, you pay nothing more for covered drugs.	$0 for all covered prescriptions for the rest of the year.	Continues until December 31 of the plan year.

🧾 Key 2025 Updates
- The “Donut Hole” (Coverage Gap) is eliminated starting in 2025.
- The out-of-pocket cap is now $2,000 — after that, you pay $0 for covered prescriptions.
- Plans can still set a deductible (up to $590) before cost sharing begins.

Drug Formulary (Drug List)

Each plan has its own formulary, or list of covered medications.
Formularies are organized by drug tier, which determines how much you pay.
Plans must include at least two drugs in each therapeutic category, ensuring access to common treatments.

Pharmacy Network

You must fill prescriptions at a plan-approved pharmacy network to get full coverage.
Some pharmacies are “preferred” and offer lower copays, while others are “standard” network pharmacies.
Many plans also include mail-order pharmacies for a 90-day supply at a discount.

Your Plan and Pharmacy Choices Matters!

Formulary tier: Generics (lower tiers) usually cost less than brand/specialty (higher tiers).
Preferred vs. standard pharmacy: Preferred in-network pharmacies often have lower copays; out-of-network usually not covered.
- Retail vs. mail order: Many plans discount 90-day mail fills for maintenance meds.
Plan deductible & copays: Plans can set a deductible (up to the annual CMS max) and their own copay/coinsurance by tier.

Medicare Prescription Payment Plan Program

What it is Medicare Prescription Payment Plan Program?
A voluntary payment option that lets you spread your Part D out-of-pocket costs into monthly bills from your drug plan instead of paying at the pharmacy counter. All Part D and MAPD plans must offer it starting 2025. It doesn’t lower your drug costs—it just smooths them out.

Who can use it?
Anyone with a Medicare drug plan (stand-alone Part D or Medicare Advantage with drug coverage) may opt in. Plans must offer it.

Tip: People who already get Extra Help, a Medicare Savings Program, or a state pharmaceutical program often won’t benefit from this option.

How it works (at a glance)?

At the pharmacy: you pay $0 at pickup for covered Part D drugs.
Each month: your plan bills you for a capped amount that includes what you would have paid at the counter, plus any unpaid balance, divided by the months left in the year; the amount can change as you add/refill prescriptions. No enrollment fee.
Keep paying your plan premium separately (if you have one).

Dollar caps that still apply
In 2025, your annual out-of-pocket for covered Part D drugs is capped at $2,000. Hitting the cap means $0 cost for covered drugs for the rest of the year (whether or not you use the payment plan).

Enrolling (how to opt in)
Call your plan (number on your ID card) or use your plan’s website to enroll; plans confirm your start date after reviewing your request. Many plans use a short participation request form. You can enroll any time during the year (earlier is usually better so costs spread over more months).

Billing & leaving the program:

You’ll get a monthly bill showing the amount due and how to pay. If you miss a payment, the plan will send a reminder; if you still don’t pay by the date on the reminder, you’ll be removed from the Payment Plan—but no interest or late fees apply, and you still owe the balance (you can pay it all at once or continue monthly billing of the balance).
Medicare
You can leave any time by contacting your plan. Changing plans (e.g., switching Part D or MAPD) ends your participation; contact the new plan if you want to opt in again.
Medicare

When this option helps most:

You have high drug costs early in the year and want predictable monthly bills.
You prefer budgeting over point-of-sale payments. (It’s not ideal if your yearly costs are low, your costs are steady each month, you enroll late in the year, or you already get financial help like Extra Help/MSP/SPAP.)

Medicare Assistance Programs

Medicare Part D Assistance Programs help lower prescription costs in several ways. The biggest is Extra Help (LIS), which can reduce or eliminate Part D premiums, deductibles, and copays; many people qualify automatically through Medicare Savings Programs (QMB/SLMB/QI). Some states offer SPAPs for added drug help, and drugmakers/charities run Prescription Assistance Programs (PAPs) for certain medicines. In 2025, the Prescription Payment Plan lets you spread out costs monthly; insulin is capped at $35/month and recommended adult vaccines are $0 under Part D.

Medicare Assistance Programs (2025)

Program	Helps Pay For	Who Qualifies	Where to Apply
Extra Help (LIS)	Premiums, deductibles, copays	Low-income beneficiaries	Social Security
Medicare Savings Programs (MSPs)	Part A & B premiums	Low-income seniors	State Medicaid office
SPAP (State Programs)	Drug copays or discounts	Varies by state	State program office
Pharmaceutical Assistance (PAPs)	Specific brand-name or specialty drugs	Based on income and need	Manufacturer or nonprofit
IRA Drug/Vaccine Caps	Limits cost of insulin & vaccines	All Part D enrollees	Automatically applied

Medicare Part C Enrollment

You can enroll in a Medicare Advantage (Part C) plan when you first get Medicare during your 7-month Initial Enrollment Period (IEP) around your 65th birthday—once Parts A and B are active; you can also change or join a Part C plan each year during the Annual Election Period (AEP), Oct 15–Dec 7, with changes effective Jan 1. If you’re already in a Medicare Advantage plan on Jan 1, you get one additional change during the Medicare Advantage Open Enrollment Period (MA OEP), Jan 1–Mar 31, with coverage starting the first of the next month. Special Enrollment Periods (SEPs) let you join, switch, or drop a plan outside these windows after certain events (e.g., moving, losing other coverage, gaining/losing Medicaid or Extra Help); those changes typically begin the first day of the month after the plan receives your request. In every case, you must have Parts A and B, live in the plan’s service area, and apply within a valid window.

Who qualifies:
Your Initial Enrollment Period (IEP) is your first chance to sign up for Medicare when you become eligible — usually when you turn 65 (or after 24 months of disability benefits).

When You Can Enroll:
Your IEP is a 7-month window that includes:

3 months before your 65th birthday month.
Your birthday month.
3 months after your birthday month.

During this period, you can enroll in:

Medicare Part A (Hospital Insurance).
Medicare Part B (Medical Insurance).
Medicare Advantage (Part C).
Prescription Drug Plan (Part D).

When Coverage Begins:

Enroll before your birthday month: Coverage starts the first day of your birthday month.
(If your birthday is on the 1st, coverage starts the month before.)
Enroll during your birthday month: Coverage starts the first day of the following month.
Enroll 1–3 months after your birthday month: Coverage starts the first day of the month after you enroll.

Example:
If your 65th birthday is July 20:

Enroll in April, May, or June → coverage begins July 1.
Enroll in July → coverage begins August 1.
Enroll in August → coverage begins September 1.
Enroll in September → coverage begins October 1.

When does it occur?
Oct 15 – Dec 7 every year. Changes take effect Jan 1 if the plan gets your request by Dec 7.
Centers for Medicare & Medicaid Services.

What you can do:

Switch: Medicare Advantage (MA/MAPD) ⇄ another MA/MAPD.
Move: Original Medicare → Medicare Advantage (or back to Original Medicare).
Change drug plans: Join/switch/drop a Part D (PDP) or MAPD.

Your last application submitted by Dec 7 is the one that takes effect Jan 1.

What AEP is not?
AEP doesn’t guarantee you can change Medigap without underwriting (rules differ by state and circumstance).

Related window (for context):
Medicare Advantage OEP: Jan 1 – Mar 31 (for people already in MA): one change to another MA plan or drop MA to return to Original Medicare (and you can add a PDP). Coverage starts the 1st of the month after the plan gets your request.

When does it occur?
Jan 1 – Mar 31 each year. Only for people who are already enrolled in a Medicare Advantage plan as of Jan 1 (there’s also a special MA OEP for newly eligible folks—see below).

What you can do (one change only)?

Switch to another Medicare Advantage plan (with or without drug coverage), or
Drop Medicare Advantage and return to Original Medicare (and you may join a stand-alone Part D plan).

Coverage starts the 1st day of the month after the plan gets your request.

What you can’t do in MA OEP?

You cannot switch from Original Medicare to a Medicare Advantage plan.
You generally cannot enroll in or switch stand-alone Part D plans unless you’re leaving MA and going back to Original Medicare.

MA OEP for Newly Eligible Beneficiaries:
If you just got Medicare and chose a Medicare Advantage plan during your IEP, you have an additional MA OEP during the first 3 months you have Medicare to make one MA change or drop MA and return to Original Medicare (and you may add a PDP).

You may qualify for a Special Enrollment Period (SEP) if::

You move out of your current plan’s service area or gain access to new plans.
You gain or lose Medicaid, Extra Help (LIS), or eligibility for a Special Needs Plan (SNP).
You enter, live in, or leave a nursing home or long-term care facility.
Your plan terminates its Medicare contract or you qualify for another CMS-approved special situation.

What you can do:

Join, switch, or drop a Medicare Advantage (Part C) plan.
Join, switch, or drop a stand-alone Prescription Drug (Part D) plan.
Return to Original Medicare (Parts A & B) from a Medicare Advantage plan, if desired.