Medicare Part C, commonly called Medicare Advantage, is a bundled alternative to Original Medicare that covers everything Part A (hospital) and Part B (medical) cover, plus additional benefits that Original Medicare does not offer. Most plans include dental, vision, hearing, and prescription drug coverage at no extra premium beyond what you already pay for Part B. About 99% of Medicare Advantage enrollees have access to eye exams or glasses, 98% to dental care, 95% to hearing services, and 94% to a fitness benefit.
What Part C Must Cover
Every Medicare Advantage plan is legally required to cover all services that Original Medicare covers under Part A and Part B. That includes hospital stays, skilled nursing facility care, doctor visits, preventive screenings, lab work, outpatient surgery, durable medical equipment, and home health services. If Original Medicare pays for it, your Part C plan pays for it too. The rules on what qualifies are identical.
Where Part C differs is in how you access that care and what you pay at each step. Instead of Medicare’s standard 20% coinsurance on most outpatient services, your plan sets its own copays and coinsurance rates. These can be lower or higher than Original Medicare for any given service, but your total annual spending is capped by an out-of-pocket maximum, which Original Medicare does not have.
Extra Benefits Beyond Original Medicare
The supplemental benefits are the main draw for most enrollees. Nearly all Medicare Advantage plans bundle in some combination of the following:
- Dental care: Preventive cleanings and exams are standard. Many plans also cover fillings, extractions, and dentures, though comprehensive dental services require prior authorization in about 86% of plans.
- Vision: Routine eye exams and an allowance for glasses or contacts. Prior authorization applies to eye exams in roughly half of plans.
- Hearing: Hearing exams and, in many plans, partial or full coverage for hearing aids. About 54% of plans require prior authorization for hearing exams.
- Fitness programs: Gym memberships or at-home fitness kits, available in 94% of plans.
- Prescription drugs: Most Part C plans include Part D drug coverage, so you don’t need a separate prescription plan.
- Meal delivery: Temporary meal benefits after a hospital stay or surgery, available in about 70% of standard plans.
- Over-the-counter allowance: A quarterly or monthly credit for items like pain relievers, vitamins, or first-aid supplies, offered by roughly 79% of plans.
- Transportation: Rides to medical appointments, available in about 28% of standard plans.
Some plans also offer a “Part B giveback” benefit, sometimes called a premium reduction or buy-down, where the plan pays back part of your monthly Part B premium. This effectively lowers your overall Medicare cost and is one of the more heavily marketed features.
Benefits for People With Chronic Conditions
A category of benefits called Special Supplemental Benefits for the Chronically Ill (SSBCI) goes well beyond typical medical coverage. To qualify, you need a chronic condition that is life-threatening or significantly limits your health or daily function, a high risk of hospitalization, and a need for intensive care coordination. If you meet those criteria, your plan has broad flexibility in what it can offer.
These benefits can include groceries and produce delivered to your home, transportation for non-medical errands like banking or grocery shopping, pest control, air quality equipment such as portable air conditioners or air purifiers, and even social programs designed to reduce isolation. Plans can cover companion care, counseling, community club memberships, park passes, financial literacy classes, and language courses. Complementary therapies alongside traditional treatment are also permitted. The idea is that health depends on more than medical care, and plans can address the living conditions that affect whether someone ends up in the hospital.
Special Needs Plans
Medicare Advantage includes a subset of plans designed for specific populations. These Special Needs Plans come in three types. Dual Eligible SNPs (D-SNPs) serve people who qualify for both Medicare and Medicaid, helping coordinate benefits between the two programs. Chronic Condition SNPs (C-SNPs) are built around a single chronic condition or a group of related conditions. Institutional SNPs (I-SNPs) serve people living in long-term care facilities.
Enrollees in Special Needs Plans get significantly broader access to certain benefits compared to standard Medicare Advantage. About 82% of SNP enrollees have access to meal benefits (versus 70% in standard plans), 80% get transportation coverage (versus 28%), and 97% receive over-the-counter allowances (versus 79%). Bathroom safety devices are available to 68% of SNP enrollees compared to 32% in standard plans.
How HMO and PPO Plans Differ
Medicare Advantage plans come in several network structures, but the two most common are HMO and PPO. The differences affect how freely you can choose doctors and what you pay for out-of-network care.
With an HMO plan, you generally choose a primary care provider who coordinates your care and may need to provide referrals before you see a specialist. Care received outside the plan’s network is typically not covered at all, meaning you’d pay the full cost yourself. HMO plans tend to have lower premiums and copays as a tradeoff for this tighter network.
PPO plans let you see specialists without a referral and cover out-of-network care, though you’ll pay more for it than you would for the same service from a network provider. PPO plans offer more flexibility but usually come with higher cost-sharing. For 2025, PPO plans have a mandatory out-of-pocket cap of $9,350 for in-network services and $14,000 for combined in-network and out-of-network spending.
Out-of-Pocket Caps
One of the biggest financial protections in Medicare Advantage is the annual out-of-pocket maximum. Original Medicare has no cap on what you can spend in a year, but every Part C plan does. Once you hit your plan’s limit, the plan covers 100% of further costs for covered services.
For 2025, CMS sets three tiers. Plans with the lowest cost-sharing can set their cap anywhere from $0 to $4,150 for in-network care. The intermediate tier runs from $4,151 to $6,750. The mandatory maximum, which no plan can exceed, is $9,350 for in-network services. PPO plans have a separate combined limit (in-network plus out-of-network) that can go up to $14,000. The specific cap your plan uses depends on the plan you choose, so comparing this number across plans is one of the most important steps during enrollment.
New Consumer Protections for 2025
Starting in 2025, Medicare Advantage plans must send you a personalized notice between June 30 and July 31 listing any supplemental benefits you haven’t used during the first half of the year. The notice includes what each unused benefit covers, what it costs, and how to access it. This rule exists because many enrollees don’t realize they’re leaving benefits on the table.
CMS has also tightened marketing rules. Third-party marketing organizations can no longer share your personal information with other marketers without your explicit one-to-one written consent for each organization. Agent and broker compensation is now a fixed amount regardless of which plan they enroll you in, removing the financial incentive to steer you toward a plan that pays them more. Contract terms that offer volume-based bonuses for pushing specific plans are now prohibited.
When You Can Enroll
The main window to join or switch Medicare Advantage plans is the Annual Election Period, which runs from October 15 through December 7 each year. Changes you make during this period take effect January 1. If you’re already in a Medicare Advantage plan and want to switch to a different one or return to Original Medicare, you can also make one change during the Medicare Advantage Open Enrollment Period from January 1 through March 31. Outside these windows, enrollment changes are only available if you qualify for a Special Enrollment Period due to specific life events like moving to a new area or losing other coverage.