Medicare Advantage covers the same hospital and doctor visits as Original Medicare, but adds extras like dental or vision — and uses a network of doctors you must see
Medicare Advantage (also called Part C) is an alternative way to get your Medicare benefits. Instead of Original Medicare, you choose a private insurance company approved by Medicare to manage your coverage. That company must cover everything Original Medicare covers — hospital stays, doctor visits, lab tests, imaging — but they do it through their own network of providers and often add benefits Original Medicare does not offer, like dental cleanings, vision exams, or hearing aids.
The trade-off is that you must use doctors and hospitals in that plan's network. If you see an out-of-network provider without a referral, you pay more or the plan may not cover it at all. You also still pay Medicare taxes and a monthly premium to the insurance company, plus copays and deductibles when you use care.
Key Takeaways
- Medicare Advantage covers all the same services as Original Medicare — hospital, doctor, lab, and imaging — but through a private insurance company's network.
- Most plans add dental, vision, hearing, or fitness benefits that Original Medicare does not cover, though the scope varies widely by plan.
- You must use in-network doctors and hospitals; out-of-network care costs more or may not be covered unless it is an emergency.
- You pay a monthly premium to the insurance company, a yearly deductible, and copays at each visit — the amounts differ by plan and by service.
- You keep your Medicare card and your Advantage plan card; you show both when you see a doctor.
Hospital and Doctor Coverage Under Medicare Advantage
Medicare Advantage must cover inpatient hospital care, including room, meals, nursing, and tests during your stay. It covers emergency room visits, urgent care, and outpatient surgery. It covers doctor visits — both routine checkups and specialist visits — though you usually need a referral from your primary care doctor to see a specialist.
Lab work, X-rays, CT scans, and MRI imaging are covered when medically necessary. Physical therapy, occupational therapy, and speech therapy are covered for a set number of visits per year, which varies by plan. Preventive services like cancer screenings, blood pressure checks, and vaccines are covered at no copay, just as they are in Original Medicare.
The difference is that all of these services must be provided by doctors and hospitals that have signed a contract with your plan. If you go to an out-of-network provider, you may owe the full cost, or the plan may refuse to pay. Emergency care is an exception — if you have a heart attack or serious injury, the plan covers emergency treatment even at an out-of-network hospital.
Extra Benefits Most Medicare Advantage Plans Offer
Many Medicare Advantage plans include dental coverage, though the scope varies. Some plans cover two cleanings and one exam per year; others cover fillings, extractions, or root canals up to a yearly dollar limit. A few plans cover dentures or implants, but most do not. You should check your plan's summary to see what is included.
Vision coverage typically includes an eye exam and a pair of glasses or contact lenses per year. Hearing coverage often includes a hearing test and one or two hearing aids per year, though the dollar amount the plan pays varies — some plans pay $500 per aid, others pay $2,000 or more. Fitness benefits are common; many plans offer a free gym membership or fitness classes.
Some plans cover over-the-counter items like pain relievers, cold medicine, or vitamins up to a yearly dollar amount. Others cover transportation to medical appointments, meal delivery after surgery, or in-home support services. These extras are one reason people choose Advantage plans, but they are not may provide — each plan decides what to offer, and the benefits can change year to year.
What You Pay: Premiums, Deductibles, and Copays
You pay a monthly premium directly to the insurance company — this is separate from your Medicare Part B premium, which you still owe to Medicare. Many Advantage plans have a $0 premium, meaning you pay only your Part B premium to Medicare and nothing extra to the insurance company. Other plans charge $50 to $200 or more per month.
Most plans have a yearly deductible, which is the amount you must pay out of pocket before the plan starts to pay. Deductibles range from $0 to $500 or higher, depending on the plan. After you meet the deductible, you typically pay a copay each time you see a doctor — often $10 to $50 per visit — and a different copay for specialist visits, urgent care, or the emergency room.
Hospital stays usually have a copay per day for the first few days, then the plan pays the rest. Prescription drugs are covered under Part D, which is included in most Advantage plans; you pay a copay per prescription, which varies by drug and by plan. The total you pay in a year is capped — once you reach your plan's out-of-pocket maximum, the plan pays 100 percent of covered services for the rest of the year.
Services Original Medicare Covers That Advantage Plans Must Include
Medicare Advantage plans must cover everything Original Medicare covers. This includes skilled nursing facility care for up to 100 days per year after a hospital stay of at least three days. It includes home health care — nursing visits, physical therapy, and medical equipment — when you are homebound and your doctor orders it. It includes hospice care when you are terminally ill.
Mental health services are covered, including therapy and psychiatric visits. Substance abuse treatment is covered. Cardiac rehabilitation and pulmonary rehabilitation are covered when medically necessary. Durable medical equipment like wheelchairs, walkers, oxygen, and diabetic supplies are covered.
The plan cannot charge you more for these services than Original Medicare would, and in many cases the copay is lower. However, you must use in-network providers. If your plan does not have a skilled nursing facility or home health agency in its network, you may have limited choices or face delays in getting care.
Services Not Covered by Medicare Advantage
Medicare Advantage does not cover long-term custodial care in a nursing home — care that is mainly help with daily living rather than medical treatment. It does not cover assisted living facilities or adult day care. It does not cover routine dental work beyond what the plan offers (which may be nothing), routine eye exams beyond what the plan offers, or routine hearing care beyond what the plan offers.
It does not cover cosmetic surgery, weight loss surgery (unless medically necessary for a specific condition), or fertility treatment. It does not cover experimental treatments or treatments not approved by Medicare. It does not cover care outside the United States, except in limited cases when you are traveling and need emergency care.
If you need a service that is not covered, you pay the full cost yourself. This is why it is important to read your plan's summary of benefits before you enroll, especially if you know you will need a specific service like dental implants or hearing aids.
How to Find Out What Your Specific Plan Covers
Every Medicare Advantage plan publishes a document called the Summary of Benefits and Coverage. This document lists what is covered, what copays you pay, which doctors and hospitals are in the network, and what is not covered. You can find this document on the insurance company's website or by calling the plan's customer service number.
You can also use the Medicare Plan Finder tool on Medicare.gov. Enter your zip code and the medications you take, and the tool shows you all the Advantage plans available in your area, what each one covers, and what you would pay. The tool is updated every year during the open enrollment period (October 15 to December 7).
Before you enroll in a plan, call the plan's customer service line and ask about coverage for any service you use regularly or know you will need. Ask whether your current doctors are in the network. Ask what happens if you need a specialist or a service that is not in the network. Getting these answers before you enroll prevents surprises later.
Frequently Asked Questions
Can I use my Medicare Advantage plan outside my home state?
Most plans cover emergency care anywhere in the United States. Routine care is usually limited to your plan's service area, which is typically your state or region. If you travel frequently or spend winters in another state, ask your plan whether it covers routine care in that location, or whether you need to switch to a plan that serves both areas.
What happens if my doctor leaves the network?
The plan must notify you and give you time to choose a new doctor. During that transition period, you can usually continue seeing your old doctor at the in-network copay. After the transition period ends, you must switch to an in-network doctor or pay out-of-network rates. You can change plans during this time if you want to follow your doctor.
Do I need a referral to see a specialist?
Most Medicare Advantage plans require a referral from your primary care doctor before you see a specialist. Some plans do not require referrals for certain specialists like gynecologists or eye doctors. Check your plan's rules before you schedule a specialist visit, or you may owe a higher copay.
Can I switch back to Original Medicare if I do not like my Advantage plan?
Yes. You can switch during the annual open enrollment period (October 15 to December 7) or during the Medicare Advantage Open Enrollment Period (January 1 to March 31). You can also switch if you move out of your plan's service area or if you may have access to for a Special Enrollment Period due to a life change.
Are prescription drugs covered under Medicare Advantage?
Most Medicare Advantage plans include prescription drug coverage (Part D). You pay a copay per prescription, which varies by drug and by plan. Some drugs may require prior approval from the plan before the pharmacy will fill them. Check your plan's drug formulary — the list of covered medications — to see whether your prescriptions are covered.