Medicare Advantage is an alternative way to get your Medicare coverage

A Medicare Advantage plan (also called Part C) is an insurance plan run by a private company that covers the same services as Original Medicare — hospital care, doctor visits, and medical equipment. Instead of getting coverage directly from Medicare, you sign up with one of these private insurers, and they handle your claims and pay your doctors and hospitals.

The main difference from Original Medicare is that Advantage plans usually have a network — you pay less when you see doctors and hospitals in that network, and more (or nothing at all) when you go outside it. Many Advantage plans also include prescription drug coverage and extras like dental or vision, which Original Medicare does not cover.

You still pay your Part B premium to Medicare each month. On top of that, you pay the Advantage plan's premium, which can be zero dollars, though most plans charge something. You also pay copays and coinsurance when you use care.

Key Takeaways

  • Medicare Advantage plans are sold by private insurance companies and cover the same basic services as Original Medicare, but usually through a network of doctors and hospitals.
  • Most Advantage plans include prescription drug coverage and dental or vision benefits, which Original Medicare does not offer.
  • You can only sign up during the Annual Enrollment Period (October 15 to December 7 each year) unless you have a may have access to life event like moving or losing other coverage.
  • Advantage plans have out-of-pocket limits that cap how much you pay in a year, but Original Medicare does not.
  • If you switch plans or drop Advantage coverage, you may need to sign up for a separate prescription drug plan to keep that coverage.

How networks affect where you can go for care

Each Advantage plan has a list of doctors, hospitals, and other providers it contracts with — this is the network. When you use an in-network provider, your copay or coinsurance is usually lower. When you use an out-of-network provider, you pay more, and some plans do not cover out-of-network care at all except in emergencies.

Before you sign up, you should check whether your current doctors are in the plan's network. Most plans let you search their provider list online, or you can call the plan and ask. If your doctor is not in the network and you want to keep seeing them, that plan may not be the right fit for you.

Some Advantage plans are HMOs (Health Maintenance Organizations), which usually require you to pick a primary care doctor and get referrals to see specialists. Others are PPOs (Preferred Provider Organizations), which give you more freedom to see specialists without a referral, though you still pay more for out-of-network care. A few plans are PFFS (Private Fee-for-Service) plans, which work differently and are less common.

What costs you pay with an Advantage plan

With an Advantage plan, you pay several types of costs. You still send your Part B premium to Medicare each month. Then you pay the plan's monthly premium (which may be zero). When you use care, you pay copays for doctor visits (often $10 to $50 per visit), coinsurance for hospital stays or procedures (often a percentage of the cost), and deductibles before coverage kicks in.

One major difference from Original Medicare is that Advantage plans have an out-of-pocket maximum — a yearly cap on how much you pay in copays and coinsurance combined. Once you hit that limit, the plan pays 100 percent of covered services for the rest of the year. Original Medicare has no such cap, so your costs can keep climbing. The out-of-pocket maximum varies by plan but often ranges from $5,000 to $10,000 per year.

Prescription drugs are usually covered under the plan itself, not through a separate Part D plan. However, the plan's drug formulary (the list of covered drugs) may not include every medication you take, and you may have to pay more for certain drugs or go through prior authorization before the plan will cover them.

When you can sign up or switch plans

You can sign up for a Medicare Advantage plan or switch to a different one 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 during the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31 each year — during this window, you can switch to a different Advantage plan or go back to Original Medicare once per year.

If you have a may have access to life event — such as moving out of your plan's service area, losing other health coverage, getting married, or becoming a U.S. citizen — you may be able to sign up or switch outside these windows. You usually have 60 days from the event to make a change. Contact Medicare or your plan to report the event and ask whether you can enroll.

When you first turn 65 and sign up for Medicare, you have a seven-month window called the Initial Enrollment Period to choose an Advantage plan. If you miss this window and do not have other may have access to coverage, you may pay a late enrollment penalty on your Part B premium for as long as you have Medicare.

Prescription drug coverage and other benefits

Most Medicare Advantage plans bundle prescription drug coverage into the plan itself, so you do not need to buy a separate Part D plan. The plan's formulary lists which drugs are covered and at what cost. Some drugs may require prior authorization (the plan's approval before you fill the prescription), and some may be on a higher tier with a higher copay.

Beyond drugs, many Advantage plans offer benefits Original Medicare does not: dental (cleanings, fillings, sometimes dentures), vision (eye exams, glasses or contacts), hearing aids, fitness programs, or transportation to medical appointments. These extras vary widely by plan and by region. When comparing plans, check what extras each one offers and whether they are benefits you would actually use.

If you drop your Advantage plan and go back to Original Medicare, you lose the drug coverage that came with the plan. You then have 63 days to sign up for a standalone Part D prescription drug plan, or you may pay a late enrollment penalty. Plan ahead if you are thinking about switching.

How to compare plans in your area

Medicare publishes a tool called Medicare Plan Finder on Medicare.gov where you can enter your zip code and see all the Advantage plans available to you. For each plan, you can see the monthly premium, deductible, copays for common services, whether your doctors are in the network, and what extra benefits are included.

When you compare plans, write down the things that matter most to you: whether your doctors are in-network, the monthly premium, the out-of-pocket maximum, copays for the services you use most often, and any extra benefits you want. Some plans are cheaper month-to-month but have higher copays; others cost more upfront but save you money if you use a lot of care. There is no single "best" plan — it depends on your doctors, your health, and your budget.

You can also call 1-800-MEDICARE to speak with someone who can walk you through the plans available in your area, or contact the plans directly to ask questions about their networks and benefits.

What happens if you move or your plan changes

If you move to a different state or county, your current Advantage plan may no longer serve your area. When this happens, you can switch to a different 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 a change. Contact your plan or Medicare to report your move and see what options are available in your new location.

Sometimes an Advantage plan stops offering coverage in your area, or the plan is discontinued altogether. If this happens, Medicare will notify you, and you will have a special enrollment period to switch to a different plan. You will not be penalized for switching during this window.

Plans can also change their benefits, premiums, and networks from year to year. Even if you liked your plan last year, it is worth reviewing the new plan details each fall during the Annual Enrollment Period to make sure it still meets your needs.

Frequently Asked Questions

Do I have to choose a Medicare Advantage plan, or can I stay with Original Medicare?

You can choose either one. Original Medicare is run by the federal government and has no network — you can see any doctor or hospital that accepts Medicare. Advantage plans are run by private companies and usually have networks. Both are valid choices; it depends on what matters more to you: flexibility to see any doctor, or lower out-of-pocket costs and extra benefits.

What if my doctor is not in my Advantage plan's network?

You can still see that doctor, but you will pay more — either a higher copay or coinsurance, or the full cost if the plan does not cover out-of-network care. If keeping your current doctor is important to you, check the plan's network before you sign up, or choose a plan that includes your doctor. If your doctor leaves the network after you enroll, you may be able to switch plans outside the normal enrollment period.

Can I switch back to Original Medicare if I do not like my Advantage plan?

Yes. During the Medicare Advantage Open Enrollment Period (January 1 to March 31), you can switch to Original Medicare once per year. You can also switch during the Annual Enrollment Period (October 15 to December 7). If you switch, remember to sign up for a Part D prescription drug plan within 63 days, or you may pay a late enrollment penalty.

What is the out-of-pocket maximum, and why does it matter?

The out-of-pocket maximum is the most you will pay in copays and coinsurance in a year. Once you reach it, the plan pays 100 percent of covered services for the rest of that year. Original Medicare has no maximum, so your costs can keep rising. If you expect to use a lot of care, an Advantage plan's out-of-pocket cap can save you money.

Do I still pay my Part B premium if I have an Advantage plan?

Yes. You pay your Part B premium to Medicare each month, plus the Advantage plan's premium (which may be zero), plus copays and coinsurance when you use care. The Part B premium is the same whether you choose Original Medicare or an Advantage plan.