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 by Medicare itself — that covers the same services Medicare Part A and Part B cover. Instead of going to any doctor who accepts Medicare, you use doctors and hospitals in that plan's network. The plan collects a monthly payment from Medicare on your behalf, and you pay a premium to the insurance company (which may be zero dollars, though many plans charge one).

The main trade-off is straightforward: Medicare Advantage plans often cost less out of pocket than Original Medicare, but they limit where you can go for care. You pick a plan each year during the annual enrollment period (October 15 to December 7), and your coverage changes on January 1.

Key Takeaways

  • Medicare Advantage plans are sold by private insurance companies and cover the same basic services as Original Medicare, but through a network of doctors and hospitals you must use.
  • Most Medicare Advantage plans include prescription drug coverage (Part D) and dental or vision benefits that Original Medicare does not offer.
  • You pay a monthly premium to the insurance company, which varies by plan and location, and you have an out-of-pocket maximum that limits your total yearly costs.
  • You can only join or switch Medicare Advantage plans during the annual enrollment period (October 15 to December 7) unless you have a may have access to life event.
  • If you travel outside your plan's service area, you may not be covered except in emergencies, so Medicare Advantage works best if you stay in one region.

How costs work in a Medicare Advantage plan

Medicare Advantage plans have four types of costs: the monthly premium you pay the insurance company, the copay you pay when you see a doctor (a fixed dollar amount like $25), the coinsurance you pay as a percentage of the cost, and the deductible you pay before the plan starts paying. Some plans have a zero premium but higher copays. Others charge a premium and have lower copays. The plan's documents will show you all four.

Every Medicare Advantage plan has an out-of-pocket maximum — a yearly limit on what you pay for covered services. Once you reach that number, the plan pays 100 percent of covered costs for the rest of the year. This maximum varies by plan but is capped by Medicare at a certain amount each year. This is different from Original Medicare, which has no out-of-pocket maximum.

If you need a service that is not in your plan's network, you may have to pay the full cost yourself, or the plan may cover it at a higher copay. Always check your plan's coverage before scheduling care outside the network.

Network restrictions and where you can get care

Medicare Advantage plans use networks — lists of doctors, hospitals, and specialists who have agreed to work with that insurance company. You must use doctors in your plan's network for non-emergency care. If you see a doctor outside the network, you may owe the full bill, or the plan may cover only part of it at a much higher cost to you.

Some plans are Health Maintenance Organizations (HMOs), which require you to pick a primary care doctor who coordinates all your care and gives referrals to specialists. Others are Preferred Provider Organizations (PPOs), which let you see specialists without a referral and may cover some out-of-network care, though at a higher cost. A few are Private Fee-for-Service plans, which work differently and are less common.

If you travel or move, check whether your plan covers care in other states. Most Medicare Advantage plans only cover emergency care outside their service area. If you spend winters in another state or travel frequently, this matters — you may need a plan that covers your second location, or you may need to switch plans when you move.

Prescription drugs and extra benefits

Most Medicare Advantage plans include prescription drug coverage (Part D) as part of the plan, unlike Original Medicare, where you buy Part D separately. The plan's formulary — its list of covered drugs — may not include every medication you take. Before you join, check whether your current prescriptions are on the formulary and at what copay.

Many Medicare Advantage plans also offer benefits that Original Medicare does not: dental care (cleanings, fillings, sometimes dentures), vision care (eye exams, glasses, contacts), hearing aids, fitness programs, or transportation to medical appointments. These extras vary widely by plan and location. Some plans offer all of them; others offer none. Check the plan's summary to see what is included.

These extra benefits are why many people choose Medicare Advantage, especially if they need dental work or glasses. However, the network restrictions and out-of-pocket costs may outweigh the extras if you have complex medical needs or see many specialists.

When you can enroll or switch plans

You can join a Medicare Advantage plan only during specific times. The main enrollment window is October 15 to December 7 each year, when you can join, switch, or drop a plan. Coverage starts January 1. If you miss this window, you cannot join until the next October unless you have a may have access to life event — such as losing other health coverage, moving to a new state, getting married, or having a baby.

If you are new to Medicare (turning 65 or becoming may be able to access due to disability), you have a seven-month enrollment window that starts three months before the month you turn 65 or become may be able to access. During this time, you can join any Medicare Advantage plan without waiting for the annual period.

Once you are enrolled in a Medicare Advantage plan, you stay in it until you make a change. If you want to switch to a different Medicare Advantage plan or go back to Original Medicare, you must wait until the next October 15 to December 7 window — unless you have a may have access to event.

Medicare Advantage versus Original Medicare

The choice between Medicare Advantage and Original Medicare depends on your health, where you live, and how much you are willing to pay upfront. Original Medicare (Part A and Part B) has no network — you can see any doctor who accepts Medicare anywhere in the country. You pay a deductible and coinsurance, but there is no out-of-pocket maximum, so costs can be very high if you have a serious illness.

Medicare Advantage costs less out of pocket for many people because of the out-of-pocket maximum and included extras like dental and vision. But if you have a chronic condition that requires many specialist visits, the network restrictions and referral requirements may be frustrating. If you travel frequently or live part of the year in multiple states, Original Medicare is usually simpler.

There is no "best" choice — it depends on your situation. Some people switch back and forth: they might use Medicare Advantage during healthy years and switch to Original Medicare if they develop a serious condition that requires many out-of-network specialists.

Questions to ask your doctor and insurance company

Before you join a Medicare Advantage plan, ask your current doctors whether they are in the plan's network. Call the plan directly or use its website to search for your doctors by name. If your main doctor is not in the network, ask whether they accept the plan or whether you would need to switch.

Ask your plan about coverage for any regular medications you take, any specialists you see regularly, and any procedures you are planning. Ask what the out-of-pocket maximum is and what it covers. Ask whether the plan covers care in other states if you travel or have a second home.

If you have questions about whether a service is covered, call the plan's customer service number on your insurance card. Do not assume — plans vary widely, and a five-minute call can save you hundreds of dollars.

When to seek help understanding your options

If you are overwhelmed by the choices, your State Health Insurance information Program (SHIP) offers free counseling about Medicare plans. You can find your state's SHIP by calling 1-800-MEDICARE or visiting Medicare.gov. A counselor can walk you through the plans available in your area and help you compare costs based on your doctors and medications.

Your local Area Agency on Aging may also have resources or counselors who can help. If you are already enrolled in a Medicare Advantage plan and think you made a mistake, you may be able to switch during a special enrollment period if you have a may have access to event — ask your plan or SHIP whether you may have access to.

Frequently Asked Questions

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

Most Medicare Advantage plans cover emergency care anywhere in the United States, but routine care is only covered in your plan's service area. If you spend winters in Florida or travel frequently, check your plan's coverage map before enrolling. Some plans cover a broader area; others are very limited geographically.

What happens if my doctor leaves the network?

If your doctor leaves the plan's network, you will need to find a new in-network doctor or pay out-of-network rates. The plan should notify you of network changes, but it is worth checking your plan's website periodically to confirm your doctors are still in the network.

Can I switch from Medicare Advantage back to Original Medicare?

Yes, but only during the annual enrollment period (October 15 to December 7) or if you have a may have access to life event. If you switch to Original Medicare, you will need to buy a Medigap policy separately to cover costs that Medicare does not pay, and you will need to enroll in Part D for prescription drugs.

Do all Medicare Advantage plans include dental and vision?

No. Some plans include comprehensive dental and vision benefits; others include limited benefits or none at all. Always check the plan's summary of benefits before enrolling. The extras offered vary by plan and location, so compare what each plan in your area includes.

What is the difference between an HMO and a PPO Medicare Advantage plan?

An HMO requires you to pick a primary care doctor and get referrals to see specialists. A PPO lets you see specialists without a referral and may cover some out-of-network care at a higher cost. PPOs are usually more flexible but may have higher premiums or copays than HMOs.