What to Compare When You're Looking at Medicare Advantage Plans

Medicare Advantage plans differ in three concrete ways: which doctors and hospitals you can use, what you pay out of pocket, and what services they cover beyond what Original Medicare covers. You cannot compare them fairly by looking at the premium alone — a plan with a $0 monthly cost might have a $6,700 deductible, while a plan charging $150 a month might have a $500 deductible and cover dental.

The comparison process has two stages. First, you narrow the list to plans that include your doctors and hospitals. Second, you compare costs and coverage for the services you actually use. Most people skip the first step and regret it when they discover their preferred doctor is out of network.

Medicare publishes a comparison tool at Medicare.gov, but it works best when you know what you are looking for. This guide walks you through what to look at and in what order.

Key Takeaways

  • Start by checking whether your current doctors and hospitals are in-network for each plan, because switching providers is the most common reason people regret their choice.
  • Compare the deductible, copays, and coinsurance amounts for the services you use most often — not the premium, which is only one part of what you pay.
  • Check the formulary (the list of covered drugs) for any prescriptions you take regularly, because coverage and cost-sharing vary widely between plans.
  • Look at the out-of-pocket maximum, which is the most you will pay in a year before the plan covers everything at no cost.
  • Use Medicare.gov's plan comparison tool or call 1-800-MEDICARE to see side-by-side costs for your specific situation.

Step 1: Check Your Doctors and Hospitals Are In-Network

Before you look at anything else, verify that the doctors you see regularly accept each plan you are considering. Medicare Advantage plans are networks — they only cover care from doctors and hospitals that have signed a contract with the plan. If your cardiologist or primary care doctor is not in the network, you will either pay out-of-pocket to see them or switch doctors.

Each plan publishes a provider directory online. Go to the plan's website and search for your doctor by name, or search by specialty and location. If the directory is hard to navigate, call the plan's customer service number and ask directly: "Is Dr. [name] in-network for this plan?" Write down the answer and the date you called, in case you need to dispute it later.

Do this for every doctor you see regularly — your primary care doctor, any specialists, your dentist if the plan covers dental, and your eye doctor if it covers vision. If even one important doctor is out-of-network, that plan is probably not the right fit, no matter how cheap the premium is.

Step 2: Compare What You Pay Out of Pocket

Once you have narrowed the list to plans with your doctors in-network, compare the actual costs. Medicare Advantage plans charge four types of out-of-pocket costs: a monthly premium, a deductible (the amount you pay before the plan starts sharing costs), copays (a fixed dollar amount per visit), and coinsurance (a percentage of the cost). Some plans have all four; others have none.

The easiest way to compare is to list the costs for the services you use most. If you see your primary care doctor four times a year and take one prescription drug, calculate what you would pay under each plan for those specific things. Here is what to look for:

  • Monthly premium: What you pay every month, regardless of whether you use the plan.
  • Primary care visit copay: What you pay each time you see your main doctor.
  • Specialist visit copay: What you pay to see a specialist (often higher than primary care).
  • Hospital stay copay or coinsurance: What you pay if you are admitted to the hospital.
  • Prescription drug costs: The copay or coinsurance for each drug you take (see the next section).
  • Out-of-pocket maximum: The most you will pay in a year; after you hit this number, the plan covers everything at no cost.

Write these numbers down for each plan in a straightforward table. Add them up for a typical year based on your actual doctor visits and prescriptions. The plan with the lowest total is usually the best choice, even if it does not have the lowest premium.

Step 3: Check the Drug Formulary

If you take prescription drugs, the formulary — the list of drugs the plan covers — is one of the most important things to check. Two plans might both cover your blood pressure medication, but one might charge a $10 copay and the other a $50 copay. Some plans do not cover certain drugs at all, or they require you to try a cheaper drug first before they will cover the one your doctor prescribed.

Each plan publishes its formulary online. Search for each of your regular medications by name. Write down the copay or coinsurance amount for each one. If a drug is not on the formulary, call the plan and ask whether they cover it under a different name (sometimes a generic version is covered but the brand name is not) or whether you can request an exception from your doctor.

Pay special attention to drugs that are on the formulary but in a higher "tier" — plans often charge more for newer or brand-name drugs than for older generic ones. If your doctor prescribed a brand-name drug and the plan covers a generic version for less, ask your doctor whether the generic would work for you.

Step 4: Look at Extra Benefits

Many Medicare Advantage plans cover services that Original Medicare does not, such as dental, vision, hearing aids, or fitness programs. If you use these services, the value of the extra benefit might outweigh a higher premium or higher copays for doctor visits.

Check what each plan covers under "additional benefits" or "supplemental benefits." Common ones include:

  • Dental (cleanings, fillings, extractions — coverage limits vary widely)
  • Vision (eye exams, glasses, contact lenses)
  • Hearing (exams and hearing aids)
  • Fitness (gym memberships or in-home exercise programs)
  • Transportation (rides to medical appointments)
  • Meal delivery (after a hospital stay or for certain chronic conditions)

If a plan covers dental and you need a crown, that could save you $1,000 or more. If it covers fitness and you use a gym, that could save you $50 to $100 a month. Add the value of these benefits into your cost comparison.

Step 5: Use Medicare.gov to Compare Plans Side by Side

Medicare.gov has a plan comparison tool that lets you enter your doctors, drugs, and hospitals and see costs for multiple plans at once. Go to Medicare.gov, click "Find Care Providers and Suppliers," and then select "Compare Medicare Advantage Plans." You will need your zip code and the names of your doctors and drugs.

The tool shows you which plans include your doctors, what the premium is, what the deductible is, and what you would pay for your specific drugs. It does not show everything — you will still need to check the formulary and provider directory yourself — but it gives you a quick way to narrow the field.

If you do not want to use the online tool, call 1-800-MEDICARE and a representative can walk you through the comparison over the phone. They can also answer questions about specific plans and help you understand the differences.

Common Mistakes to Avoid

The biggest mistake is choosing a plan based on the premium alone. A $0 premium plan might sound great until you realize the deductible is $6,700 and your doctor is out-of-network. Spend the time to calculate what you would actually pay.

The second mistake is not checking the formulary before you enroll. If your plan does not cover your blood pressure medication or charges a much higher copay than you expected, you cannot change plans until the next open enrollment period (usually October 15 to December 7). Check the formulary before you commit.

The third mistake is assuming that because a doctor was in-network last year, they will be in-network this year. Networks change. Check the current provider directory every year during open enrollment, even if you are thinking about staying with the same plan.

Frequently Asked Questions

Can I switch Medicare Advantage plans if I change my mind?

You can switch during the annual open enrollment period, which runs from October 15 to December 7 each year. Changes take effect January 1. If you are new to Medicare, you have a 3-month window to enroll. Outside these windows, you can only switch if you have a may have access to life event, such as moving out of the plan's service area or losing employer coverage.

What is the difference between HMO and PPO Medicare Advantage plans?

HMO plans require you to use in-network doctors and usually require a referral from your primary care doctor to see a specialist. PPO plans let you see out-of-network doctors, but you pay more. HMO plans usually have lower premiums and copays; PPO plans cost more but give you more flexibility. Both are types of Medicare Advantage.

Do I need to pick a primary care doctor?

Most Medicare Advantage plans require you to choose a primary care doctor, and some require a referral to see a specialist. A few plans (usually PPOs) do not. Check the plan's rules when you compare. If you do not want to be tied to one doctor, a PPO or a plan without a primary care requirement might be better for you.

What happens if my doctor leaves the network after I enroll?

If your in-network doctor leaves the plan, you have the right to continue seeing them for a limited time (usually 30 to 90 days) while you find a new doctor. If you cannot find an in-network replacement, you may be able to switch plans outside the normal open enrollment period. Contact the plan when ready if this happens.

Are there plans with $0 premium and low copays?

Some plans do offer $0 premiums with low copays, but they usually have higher deductibles or narrower networks. Compare the total cost you would pay in a year, not just the premium. A plan that costs $150 a month but has a $500 deductible might be cheaper overall than a $0 premium plan with a $6,700 deductible.