What Medicare Advantage Is

Medicare Advantage is an alternative way to receive your Medicare benefits. Instead of using Original Medicare (Part A and Part B), you join a private insurance plan that contracts with Medicare to cover the same services. The plan acts as the middleman between you and Medicare — you pay your premiums to the plan, not to Medicare, and the plan is responsible for paying your doctors and hospitals.

Medicare Advantage plans must cover everything Original Medicare covers, but they often add extra benefits that Original Medicare does not — like dental, vision, hearing, or fitness programs. However, they also come with different rules about which doctors you can see and how much you pay out of pocket.

These plans are sometimes called "Part C" because that is the Medicare part number assigned to them. They are offered by insurance companies like UnitedHealthcare, Humana, Anthem, and Aetna, as well as regional insurers in your state.

Key Takeaways

  • Medicare Advantage is a private insurance plan that replaces Original Medicare and must cover the same basic services, but often includes dental, vision, or hearing benefits that Original Medicare does not.
  • You must have both Medicare Part A and Part B to join a Medicare Advantage plan, and you cannot use Original Medicare at the same time.
  • Most Medicare Advantage plans use networks, meaning you pay less if you see doctors and hospitals in the plan's network and more if you go out of network.
  • Your out-of-pocket costs depend on which plan you choose — some have low premiums but high deductibles, while others have higher premiums but lower costs when you use care.
  • You can switch to a different Medicare Advantage plan or back to Original Medicare once a year during the Annual Enrollment Period, which runs from October 15 to December 7.

How Medicare Advantage Plans Work

When you enroll in a Medicare Advantage plan, you are choosing a specific insurance company to manage your Medicare benefits for that year. You pay a monthly premium to that plan (in addition to your Part B premium, which you still owe to Medicare). The plan then pays your doctors, hospitals, and other providers when you receive care.

Most Medicare Advantage plans are Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). HMO plans require you to choose a primary care doctor and get referrals to see specialists; you pay little or nothing if you stay in network, but pay much more or nothing at all if you go out of network. PPO plans let you see any doctor without a referral, but you pay less in network and more out of network.

Every plan has a network — a list of doctors, hospitals, and pharmacies that have agreed to work with that plan. Before you join, you should check whether your current doctors are in the plan's network, because switching doctors mid-year is difficult.

What Medicare Advantage Covers

All Medicare Advantage plans must cover the same basic services that Original Medicare covers: hospital stays (Part A), doctor visits and outpatient care (Part B), and prescription drugs (Part D). This means you are not losing any core coverage by switching from Original Medicare to Medicare Advantage.

Many Medicare Advantage plans also cover services that Original Medicare does not cover at all. Common add-ons include dental care (cleanings, fillings, extractions), vision care (eye exams, glasses, contact lenses), hearing aids, transportation to medical appointments, fitness programs, and over-the-counter drug allowances. The specific benefits vary widely by plan and by region — a plan available in one state may not be available in another, and the benefits may differ.

To see exactly what a plan covers, you need to read its Summary of Benefits and Coverage document, which every plan must provide. This document lists what is covered, what you pay, and what is not covered. Medicare.gov lets you compare plans side by side and see these documents for free.

Costs You Pay With Medicare Advantage

Your total cost for a Medicare Advantage plan includes several pieces. First, you still pay your Part B premium to Medicare each month (currently $164.90 for most people in 2024, though this amount changes yearly). Second, you pay a plan premium to the insurance company — this can be $0 per month for some plans, or $50 to $200+ per month for others.

Beyond premiums, you pay when you use care. Most plans charge a copay (a flat fee, like $15 for a doctor visit) or coinsurance (a percentage of the cost, like 20%). You also pay a deductible before the plan starts paying — this can be $0 or several hundred dollars depending on the plan. All plans have an out-of-pocket maximum, which is a yearly cap on what you pay; once you reach it, the plan pays 100% of covered services for the rest of that year.

The trade-off is this: plans with low or zero premiums often have higher deductibles and copays, while plans with higher premiums often have lower out-of-pocket costs. There is no single "cheapest" plan — it depends on how much care you use and which doctors you see.

Medicare Advantage vs. Original Medicare

The main difference is control versus flexibility. With Original Medicare, you can see any doctor or hospital that accepts Medicare, anywhere in the country. You have no network restrictions. However, you pay a Part B premium, and you must buy a separate Medigap or Part D plan to cover gaps in coverage.

With Medicare Advantage, you are locked into a network (unless you have a PPO, which is more flexible). You cannot see out-of-network providers without paying much more, and you cannot use Original Medicare at the same time. However, you get prescription drug coverage and often extra benefits like dental or vision built in, and your total premium may be lower.

Original Medicare also works the same way everywhere in the country, while Medicare Advantage plans vary by region. A plan available in your county may not be available in the next county over, and the benefits change every year.

When You Can Enroll or Switch Plans

You can join a Medicare Advantage plan when you first become may be able to access for Medicare (usually at age 65). If you miss that window, you can only join during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Coverage begins January 1 of the following year.

If you are already in a Medicare Advantage plan, you can switch to a different plan or back to Original Medicare during the same October 15 to December 7 window. You can also switch if you have a may have access to life event — such as moving to a new state, losing your current coverage, or getting married — which opens a 60-day window to make changes.

There is one exception: if you are still working and covered by your employer's health plan, you may have different enrollment rules. Ask your employer's benefits office or call Medicare at 1-800-MEDICARE to confirm your specific situation.

Questions to Ask Your Doctor Before Enrolling

Before you choose a Medicare Advantage plan, contact your current doctors and ask whether they accept that specific plan. Do not assume — plans change their networks every year, and a doctor who accepted the plan last year may not accept it this year. Ask your doctor's office to confirm in writing.

Also ask whether your doctor has any restrictions on referrals or prior authorization (a requirement to get the plan's permission before certain treatments). If your doctor does not accept the plan, ask whether they can recommend a doctor in the plan's network, or whether switching plans might be worth it to keep your current doctor.

If you take prescription medications, check the plan's formulary (its list of covered drugs) to make sure your medications are covered and at what cost. Formularies change yearly, so check every year during enrollment season.

When to Contact Medicare or Your Plan

Call Medicare at 1-800-MEDICARE (1-800-633-4227) if you have questions about how Medicare Advantage works, want to compare plans, or need help enrolling. This service is free and available 24 hours a day, 7 days a week. You can also visit Medicare.gov to compare plans, read plan documents, and enroll online.

Once you are enrolled in a plan, contact your plan directly with questions about your coverage, your network doctors, or claims. Your plan's customer service number is on your insurance card.

Seek when ready care if you have chest pain, difficulty breathing, signs of stroke, or other emergency symptoms — go to the nearest emergency room. Medicare Advantage plans must cover emergency care even if the hospital is out of network.

Frequently Asked Questions

Do I have to join a Medicare Advantage plan?

No. Medicare Advantage is optional. You can stay on Original Medicare instead. However, if you want prescription drug coverage with Original Medicare, you must buy a separate Part D plan. Many people choose Medicare Advantage because it bundles drug coverage and extra benefits together.

What happens if I move to a different state?

Your Medicare Advantage plan may not be available in your new state, or the benefits may be different. When you move, you have 60 days to switch to a different plan or back to Original Medicare. Contact your plan or Medicare as soon as you know your move date so you can explore your options.

Can I use my Medicare Advantage plan when I travel?

It depends on the plan. HMO plans usually do not cover care outside their service area except in emergencies. PPO plans typically cover care anywhere in the United States, though you pay more out of network. Check your plan's documents or call customer service before you travel.

What if I am unhappy with my plan during the year?

You cannot switch plans in the middle of the year unless you have a may have access to life event (moving, losing coverage, getting married, or other major changes). Your next opportunity is the Annual Enrollment Period in October. However, you can contact your plan to discuss your concerns — sometimes they can address coverage issues or help you understand your benefits better.

Do I still pay my Part B premium if I join Medicare Advantage?

Yes. You must continue paying your Part B premium to Medicare, even though you are using a private plan. The plan premium is separate and goes to the insurance company. Some plans have a $0 plan premium, but you still owe Part B.