Medicare Advantage is an alternative way to get your Medicare benefits through a private insurance company

A Medicare Advantage plan (also called Part C) is health insurance sold by a private company — not the government — that covers everything Original Medicare covers, plus usually dental, vision, and hearing. You still pay your Part B premium to Medicare, but you get your coverage through the insurance company instead of directly from Medicare. The trade-off is that most Advantage plans limit which doctors and hospitals you can use, and they often require you to get approval before certain treatments.

You do not have to choose a Medicare Advantage plan. You can stay with Original Medicare (Part A and Part B) and buy a separate Medigap or Part D plan if you want. But if you do choose Advantage, you are switching how your benefits work for that year — you cannot use your Original Medicare coverage at the same time.

Key Takeaways

  • Medicare Advantage plans are run by private insurance companies and usually cost less out of pocket than Original Medicare plus Medigap, but they limit which doctors you can see.
  • You pay a monthly premium to the insurance company (in addition to your Part B premium to Medicare), a copay or coinsurance when you use care, and sometimes a deductible.
  • Most plans use a network — you pay less if you see doctors and hospitals in the plan's network, and more (or nothing is covered) if you go out of network.
  • You must get prior authorization from the plan before certain procedures, tests, or hospital stays, or the plan may not pay.
  • You can switch plans or go back to Original Medicare only during the annual enrollment period in the fall, with a few exceptions.

What you pay each month and when you use care

Medicare Advantage plans charge three types of costs. First, you pay a monthly premium to the insurance company — this is separate from your Part B premium, which you still owe to Medicare. Some plans have a zero premium, meaning you pay nothing extra beyond your Part B premium, but these are less common and usually have higher copays. Second, you pay a copay or coinsurance each time you see a doctor, fill a prescription, or use a service. A copay is a flat amount (like $25 to see your doctor); coinsurance is a percentage of the cost (like 20%). Third, many plans have a deductible — an amount you must pay out of your own pocket before the plan starts paying.

Most Advantage plans also set an out-of-pocket maximum. Once you reach this limit in a calendar year, the plan pays 100% of your covered costs for the rest of that year. This maximum varies by plan but is capped by Medicare — in 2024, no plan can charge more than $8,050 per person. This is different from Original Medicare, which has no out-of-pocket cap, which is why some people buy Medigap to protect against very high costs.

How networks work and what happens if you go out of network

Almost all Medicare Advantage plans use a network — a list of doctors, hospitals, and other providers that have agreed to work with that insurance company. When you see a doctor in the network, you pay the copay or coinsurance the plan sets. When you see a doctor outside the network, you usually pay much more, or the plan does not pay at all (except in emergencies).

Before you join a plan, you should check whether your current doctors are in the network. The insurance company's website has a provider search tool. If your main doctor is not in the network and you want to keep seeing them, you may need to choose a different plan or go back to Original Medicare. Some plans are HMOs, which usually do not cover out-of-network care except emergencies. Others are PPOs, which cover some out-of-network care but at a higher cost to you. A few plans are PFFS (Private Fee-for-Service), which work more like Original Medicare but still require you to check that doctors will accept that plan.

Prior authorization and when the plan says no to treatment

Before you have certain procedures, tests, or hospital stays, your doctor must call the insurance company to get prior authorization — permission from the plan that the treatment is medically necessary. If your doctor does not get this approval and you have the procedure anyway, the plan may refuse to pay. This can happen for things like imaging (MRI, CT scan), surgery, physical therapy, or a hospital stay longer than a few days.

Sometimes the plan denies authorization — it says the treatment is not covered or is not medically necessary. Your doctor can appeal this decision, and you can appeal it too. The plan must tell you in writing why it said no and how to request a review. This process can take time, so if you need urgent care, tell your doctor and the plan right away. Emergency care does not require prior authorization; you can go to the emergency room and the plan will pay.

Prescription drug coverage included in most plans

Most Medicare Advantage plans include prescription drug coverage (Part D) as part of the plan. You do not buy a separate Part D plan. The plan has a formulary — a list of drugs it covers — and you pay a copay when you fill a prescription. Like standalone Part D plans, Advantage drug coverage has a deductible, a coverage gap (sometimes called the "donut hole"), and a catastrophic coverage phase. The specifics vary by plan.

If the plan does not cover a drug your doctor prescribed, you can ask the plan for an exception. Your doctor can request that the plan cover it anyway, especially if you have tried other drugs on the formulary and they did not work. This takes a few days to a week, so plan ahead if you are running low on medication.

Dental, vision, and hearing benefits

One reason many people choose Medicare Advantage is that most plans include dental, vision, and hearing benefits that Original Medicare does not cover. However, these benefits are limited. Dental usually covers cleanings and X-rays but may have a yearly maximum (like $1,000 or $1,500) and may not cover major work like crowns or root canals, or covers them at a lower percentage. Vision typically covers an eye exam and may help pay for glasses or contacts, but the allowance is often modest. Hearing usually covers a hearing test and may help pay for one or two hearing aids every few years.

These benefits vary widely between plans. Before you join, look at what each plan covers and whether it is enough for your needs. If you need a lot of dental work, for example, a plan with a $1,000 annual maximum may not be worth it.

When you can switch plans or go back to Original Medicare

You can change your Medicare Advantage plan or switch to Original Medicare during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect on January 1. You cannot switch at other times of year unless you have a may have access to life event — you moved out of the plan's service area, you lost other insurance, you were in a nursing home and are now leaving, or a few other specific situations. If you have a may have access to event, you have 60 days to make a change.

If you decide to leave your Advantage plan and go back to Original Medicare, keep in mind that you may not be able to buy a Medigap policy, or if you can, it may be more expensive or have waiting periods. Some states have protections that let you buy Medigap within a certain window, but not all do. Ask about this before you switch.

Questions to ask your doctor and the insurance company

Before you join a Medicare Advantage plan, ask the insurance company: Is my doctor in the network? Is my pharmacy in the network? What is the copay for my regular doctor visits? What is the deductible and out-of-pocket maximum? Does the plan cover my current medications, and if not, what is the appeal process? What procedures require prior authorization?

Once you are enrolled, ask your doctor: Will you accept this insurance plan? Do you need to get prior authorization before my next procedure or test? If the plan denies a treatment you think I need, will you appeal?

Frequently Asked Questions

Can I use my Medicare Advantage plan at a hospital out of state?

Emergency care is covered anywhere in the United States. Non-emergency care out of state is usually not covered unless you are traveling and need urgent care (not emergency, but more than routine). Check your plan's rules before you travel, and carry your insurance card. If you spend winters in another state, ask whether that plan has a network there or whether you need a different plan.

What happens to my Medicare Advantage plan if I move?

If you move outside your plan's service area, you can switch to a different plan or go back to Original Medicare without waiting for the annual enrollment period. You have 60 days from the date you move to make a change. Contact your current plan to report your move and ask what options are available in your new area.

Do I still need to pay my Part B premium if I have Medicare Advantage?

Yes. You pay your Part B premium to Medicare every month, just as you would with Original Medicare. You also pay the Advantage plan's monthly premium (if it has one) to the insurance company. Some Advantage plans have zero premium, so you would pay only your Part B premium plus copays when you use care.

What if my doctor leaves the network?

If your doctor stops accepting your plan, the insurance company should notify you. You can usually continue seeing that doctor for a short transition period (often 30 to 90 days) at the in-network copay while you find a new doctor. If you want to keep seeing that doctor, you can switch to a different plan or go back to Original Medicare during the annual enrollment period.

Can I have both Medicare Advantage and Medigap at the same time?

No. If you are enrolled in a Medicare Advantage plan, you cannot buy a Medigap policy. Medigap is designed to work with Original Medicare only. If you switch from Advantage to Original Medicare, you can then buy Medigap, but timing and availability depend on your state's rules.