Medicare Advantage plans cover hospital stays, doctor visits, and prescription drugs — often with lower premiums than Original Medicare, but with networks and out-of-pocket limits you need to understand.

A Medicare Advantage plan (also called Part C) is an alternative to Original Medicare run by private insurance companies approved by Medicare. Instead of going to any doctor or hospital that accepts Medicare, you use doctors and hospitals in the plan's network. In return, the plan typically charges a lower monthly premium than Original Medicare Part B, and it bundles hospital coverage (Part A), doctor coverage (Part B), and prescription drug coverage (Part D) all in one.

What you pay out of pocket — copays, coinsurance, and deductibles — varies by plan and can change each year. Every Medicare Advantage plan must cover at least what Original Medicare covers, but plans can add extra benefits like dental, vision, or hearing. The trade-off is that you usually cannot see doctors outside the network without paying much more, and you may need referrals to see specialists.

Key Takeaways

  • Medicare Advantage plans cover hospital stays, doctor visits, and prescription drugs as a package, with a network of doctors and hospitals you must use.
  • Plans must cover at least what Original Medicare covers, but your out-of-pocket costs (copays, deductibles, coinsurance) depend on which plan you choose.
  • Many plans add extra coverage for dental, vision, hearing, or fitness programs that Original Medicare does not include.
  • You have an annual out-of-pocket maximum — once you reach it, the plan pays 100 percent of covered services for the rest of the year.
  • You can only switch plans during the annual enrollment period (October 15 to December 7) or if you have a may have access to life event.

Hospital and Emergency Care Coverage

Medicare Advantage plans cover inpatient hospital stays the same way Original Medicare does: you pay a copay (often $250 to $500 per admission) and the plan covers the rest. If you need emergency care outside your plan's service area — say you are traveling and have a heart attack — the plan must cover it as an emergency, even if the hospital is out of network. Once the emergency is over and you are stable, you are expected to transfer to an in-network hospital if possible.

Urgent care (a sprained ankle, a cut that needs stitches) is also covered, but the copay and whether the facility is in-network matter. Some plans cover urgent care centers in-network for a lower copay; others may charge more if the center is out of network. Always check your plan's list of in-network urgent care locations before you need one.

Doctor Visits and Specialist Care

Medicare Advantage plans cover doctor visits, but you typically pay a copay each time — usually $10 to $50 for a primary care visit and $25 to $75 for a specialist. You must choose a primary care doctor from the plan's network, and that doctor coordinates your care. If you want to see a specialist, many plans require your primary care doctor to send a referral first, though some plans let you self-refer to certain specialists.

If you see a doctor outside the network without a referral or emergency reason, you pay the full bill yourself — the plan does not cover it. This is the biggest difference from Original Medicare, where you can see any doctor who accepts Medicare. Before you switch to a Medicare Advantage plan, check whether your current doctors are in the network, because changing doctors mid-year can be difficult.

Prescription Drug Coverage

All Medicare Advantage plans include prescription drug coverage (Part D is built in). You pay a copay or coinsurance for each medication, and the amount depends on which "tier" the drug is on. Tier 1 drugs (usually generic) cost less; Tier 5 drugs (usually brand-name) cost more. Your plan's formulary — the list of covered drugs — determines which medications are covered and at what cost.

Like all Part D plans, Medicare Advantage plans have a coverage gap called the "donut hole." Once you and the plan have spent a certain amount on drugs in a year, you enter the gap and pay a higher percentage of the cost until you reach the out-of-pocket maximum. The exact amounts change each year. If you take expensive medications, ask the plan whether the drugs you need are on the formulary and what you will pay in the coverage gap.

Extra Benefits Many Plans Offer

Medicare Advantage plans can offer benefits that Original Medicare does not, and these vary widely by plan and region. Common add-ons include dental (cleanings, fillings, sometimes dentures), vision (eye exams, glasses, contact lenses), and hearing (exams and hearing aids). Some plans also cover fitness programs (like SilverSneakers or Renew Active), transportation to medical appointments, meal delivery, or home safety modifications.

These extras are a major reason people choose Medicare Advantage, but they are not may provide year to year. A plan that covered dental this year may drop it next year, or change what it covers. When you review plans during open enrollment, check the current year's benefits document, not last year's, because benefits change annually.

Out-of-Pocket Costs and Annual Maximums

Every Medicare Advantage plan has an annual out-of-pocket maximum — a cap on how much you pay in copays, coinsurance, and deductibles in a year. Once you reach that limit, the plan pays 100 percent of covered services for the rest of the year. The maximum varies by plan; in recent years it has ranged from around $6,700 to $10,000, but these amounts change annually.

This maximum is different from Original Medicare, which has no annual cap. If you have high medical costs, the out-of-pocket maximum can protect you. However, premiums, balance billing (charges from out-of-network providers), and costs for non-covered services do not count toward the maximum. Read your plan's summary of benefits to understand exactly what counts.

What Medicare Advantage Plans Do Not Cover

Medicare Advantage plans do not cover services that Original Medicare does not cover — things like routine eye exams (unless the plan adds it), routine dental (unless the plan adds it), hearing aids (unless the plan adds it), or long-term care in a nursing home. They also do not cover cosmetic surgery, most weight-loss surgery, or experimental treatments.

If you need a service that is not covered, you pay the full cost yourself. Some plans offer supplemental coverage for certain services, but you have to pay extra for it. Before you enroll, review the plan's coverage document to see what is and is not included.

Network Restrictions and How They Affect Your Care

The biggest limitation of Medicare Advantage is the network. You must use doctors, hospitals, and other providers in the plan's network to get the lowest cost. If you go out of network, you either pay much more or the plan does not cover it at all. Some plans allow out-of-network care in emergencies or urgent situations, but you have to pay a higher copay or coinsurance.

If you travel frequently or live part of the year in another state, check whether the plan has providers where you spend time. Some national plans have wider networks; others are regional. If you need ongoing care from a specialist who is not in-network, that specialist may not be available to you without paying out of pocket.

Frequently Asked Questions

Can I use my Medicare Advantage plan if I travel out of state?

Emergency care is covered anywhere in the United States. For routine or urgent care, it depends on the plan's network. Some national plans have providers in most states; others are regional. Before you travel, call the plan to confirm whether your doctors or urgent care centers are available where you are going.

What happens to my Medicare Advantage coverage if I move?

If you move outside your plan's service area, you can switch to a different Medicare Advantage 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 the change. Contact your current plan to report the move and find out your options.

Do I still need Medigap insurance if I have Medicare Advantage?

No. Medigap (supplemental insurance) is designed to work with Original Medicare, not Medicare Advantage. Medicare Advantage already includes hospital and doctor coverage, so Medigap would duplicate it. However, some people buy a separate plan to cover costs the Medicare Advantage plan does not, though this is less common.

Can my Medicare Advantage plan change its coverage during the year?

Plans can make limited changes mid-year, such as removing a provider from the network or changing a drug formulary. They cannot eliminate core benefits (hospital, doctor, prescription drug coverage) during the year. If a major change affects you, you may have the right to switch plans outside the annual enrollment period.

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

If your doctor leaves the network, the plan must notify you. You can usually continue seeing that doctor for a limited time (often 30 to 90 days) while you find a new in-network doctor, or you can switch to a different Medicare Advantage plan during the annual enrollment period. Contact the plan when ready to understand your options.