Medicare Advantage is an alternative way to get your Medicare benefits through a private insurance company
Instead of using Original Medicare (the government plan that covers hospital and doctor visits), you can choose a Medicare Advantage plan, also called Part C. A private insurer — like Humana, UnitedHealthcare, or Aetna — runs the plan and handles your coverage. You still pay your Part B premium to Medicare, but the private company manages your benefits, decides which doctors you can see, and sets your out-of-pocket costs.
The main trade-off is this: Medicare Advantage plans usually charge lower or zero monthly premiums and have lower deductibles than Original Medicare, but they limit which hospitals and doctors you can use. Most plans require you to stay in-network, and many require you to get a referral before seeing a specialist. In return, they often include dental, vision, and hearing coverage — things Original Medicare does not cover at all.
Key Takeaways
- Medicare Advantage plans are run by private insurance companies and include coverage for dental, vision, and hearing that Original Medicare does not offer.
- You must use doctors and hospitals in the plan's network, and most plans require referrals to see specialists.
- Out-of-pocket costs are usually lower upfront, but you may pay more per visit or service than you would under Original Medicare.
- You can switch to a different Medicare Advantage plan or back to Original Medicare during the Annual Enrollment Period each fall, or if you have a may have access to life change.
- Plans vary widely by county and year, so comparing your options each year is important even if you are happy with your current plan.
How Medicare Advantage plans cover your medical care
When you join a Medicare Advantage plan, you receive a card from the private insurance company. You use that card at any doctor or hospital in the plan's network. The private insurer decides how much you pay for each visit, test, or procedure — not Medicare. Some plans charge a copay (a flat fee like $20 for a doctor visit), others use coinsurance (you pay a percentage of the cost), and some use a deductible you must meet first.
Most Medicare Advantage plans are HMO plans (Health Maintenance Organization), which means you must choose a primary care doctor and get referrals to see specialists. Some plans are PPO plans (Preferred Provider Organization), which let you see specialists without a referral and sometimes see out-of-network doctors for a higher cost. A few plans are PFFS plans (Private Fee-for-Service), which work more like Original Medicare but are still run by a private company.
All Medicare Advantage plans have an out-of-pocket maximum — a yearly limit on what you pay. Once you reach that limit, the plan covers 100 percent of your in-network care for the rest of the year. Original Medicare has no such limit, which is why some people prefer it.
What extra benefits Medicare Advantage plans include
The biggest advantage of these plans is coverage for services Original Medicare does not pay for. Most plans include dental coverage (cleanings, fillings, sometimes dentures), vision coverage (eye exams and glasses or contacts), and hearing coverage (exams and hearing aids). Many also cover fitness programs, transportation to medical appointments, or over-the-counter medication allowances.
The scope of these extras varies by plan and by county. One plan in your area might cover two dental cleanings a year and basic fillings, while another covers major dental work. Some plans include a gym membership; others do not. You need to check the specific plan's benefits document to see what is actually covered, because the names sound similar but the details are very different.
Network restrictions and how they affect your choices
The main limitation of Medicare Advantage is that you usually cannot see any doctor you want. HMO plans require you to use in-network providers, and if you see an out-of-network doctor without a referral, you may have to pay the full cost yourself. If you travel frequently or live part of the year in another state, an HMO plan may not work for you — you would need a PPO plan or Original Medicare.
Before you join a plan, you can look up whether your current doctors are in the network. The plan's website has a provider search tool, or you can call the plan and ask. If your doctor is not in the network and you want to keep seeing them, you should not join that plan. Switching plans later is possible, but it is easier to choose the right one from the start.
Some plans cover emergency care and urgent care out-of-network, but routine visits usually must be in-network. Read the plan's summary of benefits to understand what happens if you need care outside the network.
Costs: premiums, deductibles, and out-of-pocket limits
Medicare Advantage plans often have lower or zero monthly premiums than Original Medicare with a Medigap supplement plan. Many plans charge nothing extra beyond your Part B premium. However, your costs at the doctor's office or hospital may be higher than Original Medicare, depending on the plan and the service.
Each plan sets its own deductible, copays, and coinsurance. One plan might charge $0 for a primary care visit and $50 for a specialist; another might charge $30 for both. Some plans have a yearly deductible you must pay before coverage begins; others do not. The plan's Summary of Benefits document lists all these costs, and it is worth reading before you join.
All Medicare Advantage plans have an out-of-pocket maximum, usually between $6,700 and $7,500 per year (the exact amount changes yearly). Once you reach this limit, the plan pays 100 percent of your in-network care for the rest of the year. Original Medicare has no out-of-pocket maximum, so your costs can be higher if you need a lot of care.
When you can join or switch Medicare Advantage plans
You can join a Medicare Advantage plan when you first become may be able to access for Medicare (usually at age 65) or during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect on January 1. If you miss this window, you cannot switch plans until the next October.
You can switch outside the Annual Enrollment Period if you have a may have access to life event: you move out of the plan's service area, you lose your current coverage, you become may be able to access for Medicaid, or you experience certain other changes. You have 60 days from the event to make a change. If you are unhappy with your plan mid-year and do not have a may have access to event, you are stuck until October.
If you are still working and have employer health insurance, you may be able to delay joining Medicare Advantage until you retire, depending on your employer's plan. Talk to your employer's benefits office or call Medicare at 1-800-MEDICARE to understand your options.
Comparing Medicare Advantage plans in your area
Plans available to you depend on where you live. Rural areas may have only one or two plans; urban areas may have a dozen. Every plan's benefits, network, and costs are different, and they change every year. Even if you are happy with your current plan, comparing your options each fall is worth your time, because a plan that was good last year might have raised copays or dropped your doctor this year.
You can compare plans on Medicare.gov using the Plan Finder tool. Enter your zip code, the medications you take, and the doctors you want to see, and the tool shows you plans available in your area, their costs, and whether your doctors are in-network. You can also call 1-800-MEDICARE and ask a representative to walk you through your options, or contact your local Area Agency on Aging for help.
When comparing, look at the total yearly cost (premium plus expected out-of-pocket costs), whether your doctors are in-network, what extra benefits matter to you, and the plan's customer service ratings. Some plans have better ratings than others, and that can matter if you need to call with questions or problems.
Frequently Asked Questions
Can I use my Medicare Advantage plan if I travel or move?
Most HMO plans only cover care in their service area, so if you travel out of state or move, you may not be covered except for emergencies. PPO plans offer more flexibility. If you spend winters in another state, look for a plan that covers your winter location, or choose Original Medicare instead.
What happens to my Medicare Advantage plan if I move to a new county?
If you move outside your plan's service area, you have 60 days to switch to a different plan or back to Original Medicare without waiting for the Annual Enrollment Period. Contact your current plan to confirm the move triggers this right, then choose a new plan that serves your new address.
Can I switch back to Original Medicare after joining Medicare Advantage?
Yes, during the Annual Enrollment Period (October 15 to December 7) you can switch back to Original Medicare. If you switch, you should also sign up for a Medigap plan at the same time to cover costs Original Medicare does not pay. Outside the enrollment period, you can switch only if you have a may have access to life event.
Do I still need to pay my Part B premium if I have Medicare Advantage?
Yes, you pay your Part B premium to Medicare every month, even though a private company runs your Medicare Advantage plan. The plan premium (if any) is separate. Some plans charge an additional monthly premium on top of Part B; many do not.
What if my doctor leaves the Medicare Advantage plan's network?
If your doctor leaves the network mid-year, the plan should notify you and may allow you to switch to a different plan without waiting for the Annual Enrollment Period. Contact your plan when ready to ask about your options and whether you can continue seeing that doctor out-of-network temporarily.