Medicare Advantage is an alternative way to get your Medicare benefits through a private insurance company instead of the government program
Medicare Advantage, also called Part C, lets you use a private health plan — usually an HMO or PPO — to cover the same hospital and doctor visits that Original Medicare covers. The private plan receives a fixed payment from Medicare for each person enrolled, and in return it must cover everything Original Medicare covers, plus often dental, vision, or hearing benefits that Original Medicare does not.
The trade-off is that you usually have a smaller network of doctors and hospitals, and you may pay different amounts depending on which provider you see. You still pay the Part B premium to Medicare, and you may pay a monthly premium to the plan itself. You also keep your red-and-white Medicare card and your plan card.
Key Takeaways
- Medicare Advantage plans are run by private insurance companies but must cover everything Original Medicare covers, plus often add dental, vision, or hearing.
- You choose doctors and hospitals from the plan's network, and seeing an out-of-network provider usually costs more or is not covered at all.
- You pay the standard Part B premium to Medicare, plus any monthly premium the plan charges, plus copays and coinsurance when you use care.
- You can switch plans during the Annual Enrollment Period (October 15 to December 7 each year) or if you have a may have access to life event.
- Plans vary widely by location — the same plan name may not exist where you live, and coverage and costs differ by county.
How Medicare Advantage plans cover your care
Every Medicare Advantage plan must cover hospital stays, doctor visits, and medical equipment the same way Original Medicare does. But the plan decides how much you pay at each visit. One plan might charge $15 for a doctor visit and another $50 for the same visit in the same town.
Most plans also include benefits Original Medicare does not: dental cleanings, eyeglasses, hearing aids, or fitness programs. Some plans cover prescription drugs automatically; others do not. The plan's coverage document, called the Summary of Benefits and Coverage, lists exactly what is covered and what you pay.
If you see a doctor outside the plan's network, you usually pay the full cost yourself, unless it is an emergency. Some plans allow out-of-network care but charge you more. This is the biggest difference from Original Medicare, where you can see any doctor who accepts Medicare.
Types of Medicare Advantage plans and how they limit your choice of doctors
HMO (Health Maintenance Organization) plans require you to choose a primary care doctor and get a referral from that doctor before seeing a specialist. You can only see doctors and hospitals in the plan's network, except in emergencies. HMOs usually have lower premiums and copays but the least flexibility.
PPO (Preferred Provider Organization) plans let you see any doctor in the network without a referral, and you can see out-of-network doctors but pay more. PPOs cost more in monthly premiums and copays but give you more choice.
PFFS (Private Fee-for-Service) plans let you see any doctor who agrees to treat you under the plan's terms, without a network requirement. These are rare and available in only a few areas.
SNP (Special Needs Plan) plans are designed for people with specific conditions (like diabetes or heart disease), people living in institutions, or people who may have access to for both Medicare and Medicaid. You must meet the plan's criteria to join.
What you pay: premiums, copays, and out-of-pocket limits
You pay three types of costs with Medicare Advantage. First, you pay the standard Part B premium to Medicare each month — this is the same whether you choose Original Medicare or Advantage. Second, you may pay a monthly premium to the plan itself; many plans charge zero premium, but some charge $50 to $200 or more per month.
Third, you pay copays and coinsurance when you use care. A copay is a fixed amount (like $20 for a doctor visit), and coinsurance is a percentage of the cost (like 20 percent). These vary by plan and by type of care.
Medicare Advantage plans have an out-of-pocket maximum — a yearly limit on what you pay for in-network care. Once you reach it, the plan pays 100 percent of covered in-network care for the rest of that year. The maximum varies by plan but is capped by federal law. Out-of-network care usually does not count toward this limit.
How to find and compare plans in your area
Plans available to you depend on where you live. The same plan name may not exist in your county, and plans that do exist may have different costs and networks. The official Medicare Plan Finder at Medicare.gov lets you enter your zip code and see which plans are available, what doctors are in each network, and what each plan costs.
You can also call 1-800-MEDICARE to speak with someone who can help you compare plans by phone. Some State Health Insurance information Programs (SHIPs) offer free, one-on-one counseling about Medicare plans; you can find your state's SHIP at shiptalk.org.
When comparing, check whether your current doctors are in the network, what the monthly premium is, what the copays are for the care you use most, and whether the plan covers prescription drugs you take. Do not choose based on premium alone — a zero-premium plan may have high copays.
When you can switch plans and what happens to your coverage
You can change Medicare Advantage plans during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect January 1. You can also switch to Original Medicare during this window if you decide Advantage is not right for you.
If you have a may have access to life event — you move out of the plan's service area, you lose Medicaid, you are admitted to a nursing home, or your plan leaves the market — you may be able to switch plans outside the enrollment period. The plan will tell you if you may have access to.
When your new plan starts, your old plan ends. Make sure you understand what happens to any prescriptions you are taking and whether your doctors accept the new plan before the switch date.
Medicare Advantage versus Original Medicare: which might work for you
Medicare Advantage works best if you are willing to use doctors in a specific network, you want dental or vision coverage, and you want a predictable out-of-pocket maximum. It also works if you do not travel much or see specialists often.
Original Medicare works better if you travel frequently, you have doctors you want to keep seeing, you are willing to buy a Medigap plan to cover gaps, or you live in a rural area where few Advantage plans operate. Original Medicare has no network, so you can see any doctor who accepts Medicare.
You do not have to choose once and stay forever. You can switch between Advantage and Original Medicare during the Annual Enrollment Period each year, so you can try Advantage and go back to Original Medicare if it does not work for you.
Frequently Asked Questions
Do I have to join a Medicare Advantage plan?
No. You can stay on Original Medicare instead. But if you do not join a plan during your initial enrollment period and you do not have a may have access to reason for the delay, you may pay a late enrollment penalty for as long as you have Medicare.
What happens if my Medicare Advantage plan stops operating in my area?
Your plan will notify you by October 31 of the year it is leaving. You can switch to another Medicare Advantage plan or to Original Medicare without penalty, and the change takes effect January 1. Medicare will help you find another plan if you need one.
Can I use my Medicare Advantage plan when I travel?
Emergency care is covered anywhere in the United States. Routine care is usually covered only in your plan's service area. If you travel often or spend winters in another state, ask the plan whether it covers urgent care out of area, or consider Original Medicare instead.
What if I am on both Medicare and Medicaid?
You may be able to join a Special Needs Plan (SNP) designed for people with dual coverage. These plans coordinate benefits between Medicare and Medicaid and often have lower copays. Ask your state Medicaid office or call 1-800-MEDICARE to find SNPs in your area.
Can I have both Medicare Advantage and a Medigap plan?
No. If you have Medicare Advantage, you cannot buy a Medigap plan. Medigap is designed to work with Original Medicare only. If you switch from Advantage to Original Medicare, you can then buy a Medigap plan, though you may pay more if you wait.