Medicare Part C (Medicare Advantage)

Medicare Part C, commonly known as Medicare Advantage (MA), is an alternative to Original Medicare offered by private insurance companies approved by Medicare. These plans bundle Part A (hospital) and Part B (medical) coverage into a single plan, and most also include Part D (prescription drug) coverage.

Medicare Advantage plans often provide additional benefits not available through Original Medicare, such as dental, vision, hearing, fitness programs, and over-the-counter allowances. In exchange, enrollees typically must use a network of providers and may need referrals to see specialists.

As of 2025, over 33 million Americans are enrolled in Medicare Advantage plans, representing more than half of all Medicare beneficiaries. Major insurers offering MA plans include UnitedHealthcare, Humana, Aetna, Cigna, Blue Cross Blue Shield, and Kaiser Permanente.

What Medicare Advantage Covers

• Everything Original Medicare (Parts A and B) covers
• Most plans include Part D prescription drug coverage
• Routine dental care (cleanings, exams, X-rays, and sometimes major dental work)
• Routine vision care (eye exams, eyeglasses, or contact lenses)
• Hearing exams and hearing aids
• Fitness and wellness programs (e.g., SilverSneakers, Renew Active)
• Over-the-counter (OTC) item allowances
• Telehealth and virtual care services
• Some plans offer meal delivery, transportation to appointments, and caregiver support

Plan Types

• HMO: Must use in-network providers; primary care physician required; referrals needed for specialists
• PPO: Can use out-of-network providers at higher cost; no referrals needed
• PFFS: Private Fee-for-Service; providers paid on plan's terms
• SNP: Special Needs Plans for specific chronic conditions, dual-eligible, or institutional populations

Who Qualifies for Medicare Advantage

• Must be enrolled in both Medicare Part A and Part B
• Must live in the plan's service area
• Cannot have End-Stage Renal Disease (ESRD) — exception: as of 2021, ESRD patients can now enroll in MA plans during open enrollment
• Must be a U.S. citizen or lawfully present in the United States

You must continue paying your Part B premium in addition to any Medicare Advantage plan premium. You cannot have a Medigap policy and a Medicare Advantage plan at the same time.

2025/2026 Medicare Advantage Costs

• Monthly Premium: Many MA plans have $0 premiums (you still pay Part B premium of $185/month). Some plans charge $10-$150/month for enhanced benefits.
• Annual Out-of-Pocket Maximum: Required by law. In 2025, the in-network MOOP limit is capped at $8,850; most plans set it lower, between $3,000 and $7,500.
• Copays: Typically $0-$30 for primary care visits; $30-$50 for specialists
• Hospital Stays: Vary by plan; often $250-$400/day for days 1-5, then $0
• Prescription Drugs: Tiered copays ranging from $0 for generics to $50-$100+ for specialty drugs
• Deductible: Some plans have $0 deductibles; others set deductibles between $100-$500

How to Enroll

• Initial Enrollment Period (IEP): 7-month window around your 65th birthday when you first become eligible for Medicare
• Annual Enrollment Period (AEP): October 15 through December 7 each year. Changes take effect January 1.
• Medicare Advantage Open Enrollment Period (MA OEP): January 1 through March 31. Allows current MA enrollees to switch to a different MA plan or return to Original Medicare.
• Special Enrollment Periods (SEPs): Available for qualifying life events such as moving out of a plan's service area, losing employer coverage, or qualifying for Medicaid.

Compare plans at Medicare.gov/plan-compare or call 1-800-MEDICARE. You can also work with a licensed insurance agent or broker at no cost.

Pros

• Annual out-of-pocket maximum protects against catastrophic costs (Original Medicare has none)
• Many plans offer $0 premiums beyond the standard Part B premium
• Extra benefits like dental, vision, hearing, fitness, and OTC allowances
• Convenient single-plan coverage combining Parts A, B, and usually D
• Growing supplemental benefits including meal delivery and transportation

Cons

• Network restrictions may limit your choice of doctors and hospitals
• May require referrals to see specialists (HMO plans)
• Coverage limited to plan's service area; emergency-only coverage when traveling
• Prior authorization requirements can delay certain treatments
• Plan benefits and networks can change annually, requiring re-evaluation each year