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. Instead of going to Medicare directly, you sign up with an insurance company like UnitedHealthcare, Humana, or Cigna, and they become your main health plan. You still pay your Part B premium to Medicare, but the insurance company handles the rest.

The trade-off is that Medicare Advantage plans have networks. You must use doctors and hospitals in that plan's network, or pay more out of pocket. Most plans also have a yearly limit on what you pay out of pocket — once you hit that limit, the plan covers the rest of your care that year. Original Medicare has no such limit.

Key Takeaways

  • Medicare Advantage plans are sold by private insurance companies and must cover at least what Original Medicare covers, plus usually add dental, vision, and hearing.
  • You must use doctors and hospitals in your plan's network, or you will pay higher costs or the plan will not cover the visit.
  • Medicare Advantage plans have a yearly out-of-pocket limit; once you reach it, the plan pays for the rest of your covered care that year.
  • You can switch plans or return to Original Medicare during the Annual Enrollment Period (October 15 to December 7 each year) or if you have a may have access to life event.
  • Your costs depend on the specific plan — some have low or zero premiums but higher copays, while others have higher premiums but lower copays.

How Medicare Advantage differs from Original Medicare

Original Medicare is run by the federal government and covers hospital care (Part A) and doctor visits (Part B). You can see any doctor or hospital that accepts Medicare, anywhere in the country. There is no network, and there is no yearly limit on what you pay out of pocket.

Medicare Advantage is run by a private insurance company. You pick a plan, and that company decides which doctors and hospitals are in-network. If you see an out-of-network doctor, you either pay the full bill yourself or the plan covers less. In return, Medicare Advantage plans usually cost less per month and include extras like dental and vision that Original Medicare does not.

The other major difference is the out-of-pocket limit. In 2024, Medicare Advantage plans must cap your yearly out-of-pocket costs at a maximum set by Medicare — this varies by plan but is typically between $6,000 and $8,000. Original Medicare has no such cap. If you have high medical costs, this limit can save you money. If you rarely see a doctor, Original Medicare may be cheaper.

Types of Medicare Advantage plans and how networks work

The most common type is a Health Maintenance Organization (HMO). In an HMO, you must choose a primary care doctor who coordinates your care and refers you to specialists. You can only see in-network doctors, and you need referrals for most specialist visits. If you see an out-of-network doctor without a referral, the plan usually will not pay.

A Preferred Provider Organization (PPO) is more flexible. You do not need a primary care doctor or referrals. You can see any doctor, but in-network doctors cost less. Out-of-network doctors cost more, but the plan still covers part of the bill. PPO plans usually have higher premiums than HMOs.

A Private Fee-for-Service (PFFS) plan lets you see any doctor who accepts the plan's payment terms — you do not have to use a network. These are less common and may not be available in your area.

Before you sign up, check whether your current doctors are in the plan's network. Call your doctor's office or use the insurance company's website to search. If your doctor is not in-network, ask whether they accept the plan or whether you would need to switch.

What Medicare Advantage plans cover

Every Medicare Advantage plan must cover everything Original Medicare covers: hospital stays, doctor visits, lab tests, X-rays, and emergency care. Many plans also cover prescription drugs (Part D), so you do not need a separate drug plan. Some plans cover dental cleanings and exams, vision exams and glasses, and hearing exams and hearing aids — but the amount of coverage varies widely.

Plans may also cover fitness programs, transportation to medical appointments, or meal delivery after surgery. These extras differ by plan and by region. When you are comparing plans, look at what each one covers, not just the monthly premium.

What Medicare Advantage plans do not cover is the same as what Original Medicare does not cover: routine dental work beyond cleanings, most vision care beyond exams, long-term care, or custodial care in a nursing home. If you need these services, you would need to buy separate insurance or pay out of pocket.

Costs: premiums, copays, and deductibles

Medicare Advantage plans have different cost structures. Some have a zero or low monthly premium but charge copays for doctor visits and hospital stays. Others have a higher premium but lower copays. You also pay the Part B premium to Medicare each month (the standard amount is $164.90 in 2024, though it may be higher if your income is above a certain level).

Most plans have a yearly deductible — the amount you pay out of pocket before the plan starts to pay. Some plans have no deductible. Once you meet your deductible, you usually pay a copay for each visit (for example, $15 for a doctor visit, $250 for a hospital stay). Specialist visits may have a higher copay.

The yearly out-of-pocket limit is the most important number to understand. Once your copays, coinsurance, and deductibles add up to this limit, the plan pays 100 percent of your covered care for the rest of that year. This limit does not include your monthly premium.

When you can sign up or switch plans

If you are new to Medicare, you can sign up for a Medicare Advantage plan when you first become may be able to access. If you already have Original Medicare or another Medicare Advantage plan, you can switch during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect on January 1.

You can also switch if you have a may have access to life event, such as moving out of your plan's service area, losing your current coverage, or getting married or divorced. You have 60 days from the event to make a change. Call Medicare at 1-800-MEDICARE to report a may have access to event.

If you switch to a Medicare Advantage plan from Original Medicare, you may want to drop your Medigap policy (supplemental insurance), because Medicare Advantage already includes some of that coverage. However, if you later switch back to Original Medicare, you may not be able to buy Medigap again at the same price, so think carefully before dropping it.

Questions to ask your doctor and insurance company

Before you sign up for a Medicare Advantage plan, call your current doctors and ask: "Are you in the network for [plan name]?" and "Do you accept this insurance?" If your doctor is not in-network, ask whether they will see you anyway and what you would pay.

Call the insurance company and ask: "What is the yearly out-of-pocket limit?" "What is the copay for a doctor visit?" "Do I need a referral to see a specialist?" and "What prescription drugs are covered?" Ask for a copy of the plan's formulary (the list of covered drugs) if you take medications regularly.

If you use a hospital or specialist regularly, ask the plan whether that facility is in-network. If you travel a lot, ask whether the plan covers emergency care outside your home state.

When to seek help or more information

If you are confused about whether Medicare Advantage is right for you, contact your State Health Insurance information Program (SHIP). SHIP is a free counseling service run by your state, and counselors can explain your options and help you compare plans. Find your state's SHIP at shiptalk.org or call 1-800-MEDICARE.

You can also call Medicare directly at 1-800-MEDICARE (1-800-633-4227) to ask questions about how Medicare Advantage works or to report a problem with your plan. If your plan denies a claim you think should be covered, you have the right to appeal. Ask your plan for the appeal process.

Frequently Asked Questions

Can I use my Medicare Advantage plan if I travel or move?

Most Medicare Advantage plans cover emergency care anywhere in the United States, but routine care must be in-network. If you move out of your plan's service area, you can switch plans during the Annual Enrollment Period or when ready if you have a may have access to life event. If you travel frequently, ask your plan whether it covers care in the areas you visit.

What happens to my Medicare Advantage plan if the insurance company stops offering it?

If your plan is discontinued, Medicare will send you a notice. You can then switch to another Medicare Advantage plan or return to Original Medicare during a special enrollment period. You have until the end of the month after you receive the notice to make a change.

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

Yes. You pay your Part B premium to Medicare each month, and then you pay the Medicare Advantage plan's premium (if it has one) separately. Some plans have zero premium, but you still owe Part B.

Can I go back to Original Medicare after I sign up for Medicare Advantage?

Yes, during the Annual Enrollment Period (October 15 to December 7) you can switch back to Original Medicare. If you drop Medigap when you sign up for Medicare Advantage, you may have trouble buying it again later at the same price, so ask about this before you switch.

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

If your in-network doctor leaves the plan, the plan must notify you and usually give you time to find a new doctor or switch plans. You may be able to switch to a different Medicare Advantage plan or return to Original Medicare outside the normal enrollment period. Contact your plan when ready if this happens.