Medicare Advantage is an alternative way to get your Medicare benefits through a private insurance company instead of Original Medicare

Medicare Advantage, also called Part C, is a plan sold by private insurers — companies like UnitedHealthcare, Humana, and Anthem — that bundles your hospital insurance (Part A) and medical insurance (Part B) into one plan. When you enroll in Medicare Advantage, you're still on Medicare, but a private company handles your coverage instead of the government. You pay a monthly premium to that company, and they decide which doctors and hospitals you can see, what prescriptions they cover, and how much you pay out of pocket.

The main trade-off is choice versus cost. Original Medicare lets you see any doctor who accepts Medicare anywhere in the country. Medicare Advantage usually limits you to a network of doctors and hospitals in your area, but the monthly premium is often lower — sometimes zero — and it includes prescription drug coverage (Part D) built in. If you travel frequently or have a doctor you're deeply attached to, this matters. If you want lower monthly costs and don't mind a smaller network, it can save you money.

Key Takeaways

  • Medicare Advantage is sold by private insurance companies and combines Part A and Part B coverage into one plan, usually with prescription drugs included.
  • Most Medicare Advantage plans use a network model, meaning you pay less when you see in-network doctors and hospitals, and more (or nothing is covered) if you go out of network.
  • You can switch to a different Medicare Advantage plan or back to Original Medicare during the Annual Enrollment Period (October 15 to December 7 each year), or if you may have access to for a Special Enrollment Period.
  • Medicare Advantage plans often have lower monthly premiums than Original Medicare plus a separate Part D plan, but you may pay more per visit or per prescription.
  • Extra benefits like dental, vision, and hearing coverage vary by plan and location — not all plans offer them, and coverage limits differ widely.

How the Network Model Works

Most Medicare Advantage plans are Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). In an HMO, you choose a primary care doctor who coordinates your care and must refer you to specialists. You pay little or nothing for in-network care but usually nothing is covered if you go out of network (except emergencies). In a PPO, you don't need a primary care doctor and can see specialists directly, but you pay more for out-of-network care than in-network care.

Some plans are Private Fee-for-Service (PFFS) plans, which work more like Original Medicare — you can see any doctor who accepts the plan — but these are less common and available in fewer areas. A few plans are Special Needs Plans (SNPs), designed for people with specific conditions like diabetes or heart disease, or for people who live in nursing homes.

The network changes every year. Your current doctor might leave the plan, or a new hospital might join. This is why it's important to check your plan's network every fall during enrollment, even if you've been happy with your plan in the past.

Costs: Premiums, Deductibles, and Out-of-Pocket Limits

A Medicare Advantage plan's monthly premium can be $0, but that doesn't mean the plan is free. You still pay your Part B premium to Medicare (the standard amount is $164.90 per month in 2024, though it varies by income). The plan's premium is what you pay the insurance company on top of that.

Most plans have a deductible — the amount you pay before the plan starts covering care. Some have no deductible for primary care visits but a deductible for specialist visits or hospital stays. You also pay copays (a fixed amount per visit) or coinsurance (a percentage of the cost). These add up until you hit your plan's out-of-pocket maximum — the most you'll pay in a year. Once you reach it, the plan covers 100% of in-network care for the rest of that year. The out-of-pocket maximum varies by plan but cannot exceed $7,550 for in-network care in 2024.

Prescription drugs are covered under the plan's formulary — a list of covered medications. You pay a copay or coinsurance for each prescription, and those costs count toward your out-of-pocket maximum. Some drugs may require prior authorization from the plan before the pharmacy will fill them.

Extra Benefits Beyond Original Medicare

Many Medicare Advantage plans include benefits that Original Medicare doesn't cover: dental (cleanings, fillings, sometimes dentures), vision (eye exams, glasses or contacts), hearing (exams and hearing aids), and fitness programs (gym memberships or Silver Sneakers). Some plans cover transportation to medical appointments, meal delivery, or home safety modifications. These extras vary widely — one plan might cover two dental cleanings a year with no copay, while another covers one cleaning with a $25 copay.

These benefits sound appealing, but read the details. A plan that advertises "dental coverage" might cover only cleanings and exams, not crowns or root canals. Hearing aid coverage might mean the plan pays $500 toward a $3,000 pair. Check what your specific plan covers before you enroll, and compare what you actually use — if you never go to the dentist, dental coverage doesn't save you money.

When You Can Enroll or Switch Plans

You can enroll in Medicare Advantage when you first become may be able to access for Medicare (usually at 65) or during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect January 1. If you miss this window, you cannot switch plans until the next October unless you may have access to for a Special Enrollment Period.

You may have access to for a Special Enrollment Period if you move out of your plan's service area, lose your plan (the insurer stops offering it in your area), or have a major life change like losing employer coverage or moving into a nursing home. You have 60 days from the event to make a change. If you're already in a Medicare Advantage plan and want to switch back to Original Medicare, you can do so during the Annual Enrollment Period, but you'll need to enroll in a separate Part D prescription drug plan at the same time.

Medicare Advantage Versus Original Medicare: The Real Differences

Original Medicare covers you anywhere in the country — you see any doctor or hospital that accepts Medicare. You pay a Part B premium, a deductible, and coinsurance (usually 20% of the cost after the deductible). You buy a separate Part D plan for prescriptions and may buy a Medigap policy to cover some of the gaps. Total monthly costs depend on how much care you use.

Medicare Advantage limits you to a network but usually has a lower or zero monthly premium and includes prescription drugs. You know your maximum out-of-pocket cost upfront. The trade-off is that you may need prior authorization for some services, you cannot see out-of-network doctors (except emergencies), and if your plan leaves your area, you have to switch. If you travel a lot or have a specialist you see regularly, Original Medicare's flexibility may be worth the higher cost. If you want predictable costs and don't mind a network, Medicare Advantage often costs less.

How to Compare Plans in Your Area

Medicare publishes a plan comparison tool at Medicare.gov where you can enter your zip code and see every Medicare Advantage plan available to you. For each plan, you can see the monthly premium, deductible, copays, which doctors and hospitals are in the network, and which drugs are covered. You can also see star ratings — Medicare rates plans on quality and customer service on a scale of 1 to 5 stars.

Don't choose based on premium alone. A plan with a $0 premium but a $500 deductible and $40 copays might cost more than a plan with a $50 premium and lower copays, depending on how often you see a doctor. Use the tool to estimate your costs based on the doctors you see and the drugs you take. Call the plan's customer service number (listed on Medicare.gov) if you have questions about whether a specific doctor is in the network or whether a specific drug is covered — the website information can lag behind real changes.

Frequently Asked Questions

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

It depends on the plan type. HMO plans usually don't cover care outside your service area except emergencies. PPO plans cover out-of-network care at a higher cost. If you travel frequently or spend winters in another state, ask the plan directly whether they cover care in the places you go, or consider Original Medicare instead.

What happens if my Medicare Advantage plan leaves my area?

If your plan stops being offered in your zip code, you'll receive a notice from the plan by October 1. You then have until December 7 to enroll in a different plan. This counts as a Special Enrollment Period, so you can switch to Original Medicare or another Medicare Advantage plan without waiting for the next October.

Do I still pay my Part B premium if I'm in Medicare Advantage?

Yes. You pay your standard Part B premium to Medicare (currently $164.90 per month for most people in 2024) plus the Medicare Advantage plan's premium, if any. Part B premium amounts vary based on income, so yours may be higher or lower.

Can I switch back to Original Medicare after I enroll in Medicare Advantage?

Yes, during the Annual Enrollment Period (October 15 to December 7). If you switch, you must also enroll in a Part D prescription drug plan at the same time, because Original Medicare doesn't include drug coverage. You may also want to buy a Medigap policy to cover costs that Original Medicare doesn't pay.

Are all Medicare Advantage plans the same?

No. Plans differ in monthly premium, deductibles, copays, which doctors and hospitals are in the network, which drugs are covered, and which extra benefits they offer. Two plans in the same area can have very different costs and coverage. Always compare plans before you enroll.