Medicare Part C: What Is It and How Does It Work?

Medicare is a health insurance program designed to cater to people aged 65 or older, younger people with disabilities, and end-stage renal disease. Medicare consists of several different plans, with each covering different aspects of healthcare and providing different services to its participants. 

These different plans offer users a range of options to choose from in terms of services provided and cost. Medicare part A covers skilled nursing facilities, hospice, and in-home care. While part B covers doctor’s visits, outpatient care, home health care, durable medical equipment, and preventive screenings. And then part D covers prescription drugs. 

Medicare part C, also known as medicare advantage, provides the benefits of both part A and B and other extra services all in one. In this article, we will be looking at what Medicare Part C is and how it works. 

What Is Medicare Part C? 

Medicare Part C, also known as Medicare Advantage Plan or MA plan, is a medical insurance plan offered by private companies that are medicare-approved and regulated. Medicare Advantage allows you to get the health services covered by Medicare part A and Part B, and even part D, plus some extra. 

So with a medicare part C plan, you may be getting benefits like fitness plans. You could also be getting covered for vision, hearing, and dental services. These are areas not covered by the original medicare. 

Most medicare advantage plans will require you to choose a Primary Care Physician to make your access to healthcare easier. This primary care physician will most likely be within the plan’s network. However, some plans allow you the flexibility of seeing other doctors and specialists outside the plan’s network. 

Some Medicare Advantage plans can also be tailored to fit certain chronic illnesses and provide the specific healthcare needs of participants suffering from such illnesses. Medicare Advantage plans also cover long-term care services like meal delivery and specialized home care. And the great news is that anyone eligible for the original medicare parts A and B is eligible for the medicare advantage plan. 

How Medicare Part C Works

There are different medicare advantage plans, and each works differently in its coverage and requirements. Here are the four most common types of Medicare Part C plans. 

1. Health Management Organisation (HMO)

In the HMO plan, healthcare services are typically provided by doctors as well as other healthcare providers and hospitals within the plan’s network. However, you may not have access to emergency care, out-of-area urgent care, and temporary out-of-area dialysis for renal patients. 

Most HMO plans cover prescription drugs, which are ordinarily covered by Medicare Part D. But you must make sure to join an HMO plan that offers coverage for prescription drugs. This means that you must ask questions before opting for an HMO plan. If you join one without drug coverage, you will not be allowed to join a separate drug coverage plan. 

 Also, in most HMO plans, you will have to choose a primary care doctor. And should you need to see a specialist, you would have to get a referral. Except for yearly screening services like mammograms. 

If your doctor or health care provider leaves the plan, you will be notified, so you can choose another within the plan. You must, however, note that any health care you receive outside the plan’s network will require you to cover the full cost. 

2. Preferred Provider Organisation (PPO)

The Preferred provider organization plan is a Medicare part C plan that allows you to use other healthcare providers that are not on the plan’s network but offer services covered by the plan. It usually costs less to use doctors, health care providers, and hospitals within the plan’s network. 

However, should you need to see specialists or other doctors not within the plan, the PPO plan offers you the flexibility to do that, but at a higher cost. As with the HMO plan, most PPO plans cover prescription drugs, but you must make sure to enroll in a plan that offers coverage for prescription drugs. 

For the PPO plan, you are not required to choose a primary health physician. And so would not need to get a referral to see a specialist. You must, however, note that seeing specialists outside the plan will cost more than in-network specialists. 

3. Private Fee for Service Plan (PFFS) 

In the PFFS medicare advantage plan, the plan determines what fee it will pay the doctors, health care providers, and hospitals and how much you will pay when you receive care from them. You can get your health care services from any doctor, health care provider, or hospital within or outside the plan’s network. 

However, your treatment may not be covered or could cost higher. In the PFFS plan, you do not need to choose a primary care doctor, and you do not need a referral to see a specialist. Some PFFS plans cover prescription drugs; however, if your plan doesn’t, you can join a separate medicare part D plan to get drug coverage. 

This is one advantage that the PFFS has over the HMO and PPO plans. Additionally, When seeing other doctors and health care providers outside the plan, you must make sure that they agree to treat you under the plan and that they accept the plan’s terms of payment. 

4. Special Needs Plan (SNP) 

The Special needs plan, as the name implies, is a type of medicare advantage plan designed especially for people with specific conditions or characteristics. The plan tailors its services, choice of healthcare providers, and drugs to meet the specific needs of its participants. 

Some special needs plans cover out-of-network services, and some do not. So you must check before enrolling. However, they usually would have specialists in the conditions or diseases that affect their members. Some SNP plans would require you to choose a primary care doctor, while some do not. 

Those that require a primary health physician will also require you to get a referral to see a specialist. One great feature of the SNP plan is that it must provide drug coverage. So you would not need to bother about joining a separate drug coverage plan. 


A medicare advantage plan allows you to access health care services that may not be available to you under the original medicare. Some Medicare Advantage plans even offer specific healthcare services for people with special needs. This means that you can get access to experts without bearing high costs. 

Some plans also provide the flexibility of seeing other healthcare providers outside the plan’s network. So you can choose to visit a general care physician near you and still get some coverage. You must, however, make sure to ask questions and be sure that a medicare advantage plan will meet your specific needs before joining. 

This is especially important if you require coverage for prescription drugs. And if you have special needs that would require specific services. On the whole, medicare advantage plans are a great way to access a wider range of healthcare services without bearing a huge financial burden.