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 the same services Medicare Part A and Part B cover. Instead of going to Medicare directly, you enroll in the private plan, and that company becomes responsible for paying your doctors and hospitals. You still pay your Part B premium to Medicare, but the private insurer handles the rest.

The main difference from Original Medicare is how the coverage works. With Original Medicare, you can see any doctor who accepts Medicare anywhere in the country. With most Medicare Advantage plans, you choose doctors from a network, and you usually need a referral to see a specialist. In exchange, these plans often include prescription drug coverage (Part D), dental, vision, or hearing benefits that Original Medicare does not cover.

Key Takeaways

  • Medicare Advantage plans are sold by private insurance companies and must cover at least the same services as Original Medicare Part A and Part B.
  • Most plans use a network of doctors and hospitals, meaning you pay less if you use in-network providers and may need referrals for specialists.
  • Many Medicare Advantage plans include prescription drug coverage, dental, vision, or hearing benefits at no extra premium.
  • You pay a monthly premium to the insurance company (in addition to your Part B premium to Medicare) and may have copays or coinsurance when you use care.
  • You can change plans or switch back to Original Medicare during the annual enrollment period, which runs from October 15 to December 7 each year.

How networks and referrals work in Medicare Advantage

Most Medicare Advantage plans are Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). An HMO requires you to choose a primary care doctor from the plan's network and get a referral before seeing a specialist. You pay less when you use in-network doctors and hospitals, and you may pay nothing or a small copay for routine visits. If you see an out-of-network doctor without an emergency, you typically pay the full cost yourself.

A PPO gives you more flexibility. You can see any doctor without a referral, and you do not have to choose a primary care doctor. However, you pay less when you use in-network providers. Out-of-network care costs more, but the plan still covers part of it. PPOs usually have higher monthly premiums than HMOs, but lower out-of-pocket costs when you need care.

Before you enroll, check whether your current doctors are in the plan's network. Plans publish their provider directories online, and you can search by doctor name or location. If your doctor is not in the network, you may need to switch doctors or choose a different plan.

What extra benefits Medicare Advantage plans often include

Many Medicare Advantage plans bundle in benefits that Original Medicare does not cover. Prescription drug coverage is included in most plans, so you do not need to buy a separate Part D plan. Dental coverage might include cleanings, exams, and fillings — though coverage limits vary widely. Vision coverage often pays for eye exams and glasses or contacts. Some plans also cover hearing aids or hearing exams.

Other plans offer fitness benefits (like a gym membership), transportation to medical appointments, or meal delivery after a hospital stay. These extras vary by plan and by region. A plan available in one county may not be available in another, and the benefits it offers may be different.

Do not assume every plan includes every benefit. Read the plan's Summary of Benefits and Coverage document before you enroll. This document lists exactly what is covered, what you pay, and what is not covered.

Costs: premiums, copays, and out-of-pocket limits

You pay three types of costs with a Medicare Advantage plan. First, you still pay your Part B premium to Medicare each month (the standard amount is deducted from your Social Security check if you receive benefits). Second, you pay a monthly premium to the insurance company — this can be zero, or it can be $50 to $200 or more, depending on the plan and your location. Third, you pay copays or coinsurance when you use care: a fixed amount per visit, or a percentage of the cost.

Medicare Advantage plans have an out-of-pocket maximum, which is a yearly limit on how much you pay for in-network care. Once you reach that limit, the plan pays 100 percent of your in-network costs for the rest of the year. Original Medicare does not have an out-of-pocket maximum, which is one reason some people prefer it. Out-of-pocket maximums vary by plan but are capped by Medicare at a certain amount each year.

If you use out-of-network care (in an HMO, or in a PPO when you choose to), those costs may not count toward your out-of-pocket maximum, or they may count differently. Check the plan's details before you enroll.

When you can enroll or change plans

You can enroll in a Medicare Advantage plan when you first become may be able to access for Medicare (usually at age 65), or during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect on January 1. If you miss this window, you cannot change plans until the next year, unless you have a may have access to life event like moving to a new state, losing other health coverage, or becoming may be able to access for Medicaid.

If you are already in a Medicare Advantage plan and want to switch to Original Medicare, you can do so during the Annual Enrollment Period. You have until December 7 to make the change, and it takes effect January 1. Some people switch back and forth depending on their health needs or whether their doctors stay in the network.

Medicare Advantage vs. Original Medicare: what to consider

Medicare Advantage works better for some people and Original Medicare for others. Choose Medicare Advantage if you want prescription drug coverage included, prefer lower monthly costs, do not mind using a network of doctors, and are willing to get referrals for specialists. It is also a good fit if you want dental or vision coverage and do not travel much outside your plan's service area.

Original Medicare may be better if you want to see any doctor anywhere without a referral, prefer not to manage a network, or travel frequently. It is also worth considering if you have a chronic condition and see many specialists, because you do not need referrals and there is no out-of-pocket maximum to worry about (though you will pay more per visit).

Your choice depends on your health, your doctors, your budget, and how much flexibility you need. You can review plans and compare costs using Medicare's Plan Finder tool on Medicare.gov, which shows plans available in your zip code and lets you enter your medications to see which plans cover them.

Frequently Asked Questions

Can I use my Medicare Advantage plan outside my home state?

Most Medicare Advantage plans only cover care within their service area, which is usually your county or a few nearby counties. If you travel or move, you may need to switch plans. Some plans marketed to snowbirds or frequent travelers offer broader coverage, but these are less common. Check the plan's service area before you enroll.

What happens to my Medicare Advantage plan if I move?

If you move to a new state or county, your current plan may no longer be available. You can change plans outside the Annual Enrollment Period because moving is a may have access to life event. Contact your plan or Medicare to find out what plans are available in your new location, and make the change before your move takes effect.

Do I still need Part D prescription drug coverage if I have a Medicare Advantage plan?

Most Medicare Advantage plans include prescription drug coverage, so you do not need a separate Part D plan. However, check your plan's details to confirm it covers the medications you take. If your plan does not cover a drug you need, you may be able to switch to a different plan during the Annual Enrollment Period.

What if my doctor leaves the Medicare Advantage plan's network?

If your doctor leaves the network mid-year, the plan usually gives you a grace period to find a new doctor or switch plans. You may be able to change plans outside the Annual Enrollment Period if your doctor leaves. Contact your plan when ready to ask about your options.

Can I go back to Original Medicare after I choose a Medicare Advantage plan?

Yes. You can switch to Original Medicare during the Annual Enrollment Period (October 15 to December 7). The change takes effect January 1. If you switch back to Original Medicare, you will need to enroll in a separate Part D prescription drug plan if you want drug coverage.