What a Medicare Advantage Plan Is

A Medicare Advantage plan (also called Part C) is an alternative way to get your Medicare coverage. Instead of using Original Medicare (Part A and Part B), you join a private insurance company that contracts with Medicare. That company becomes responsible for paying your hospital and doctor bills.

The key difference: Original Medicare is run by the federal government and covers what it covers. A Medicare Advantage plan is run by a private insurer and can add extra benefits — like dental, vision, or hearing — that Original Medicare does not include. In exchange, you usually pay a monthly premium to the insurance company on top of your Part B premium, and you have a network of doctors you must use.

You cannot have both Original Medicare and a Medicare Advantage plan at the same time. Joining one means you drop the other.

Key Takeaways

  • Medicare Advantage plans are sold by private insurance companies and must cover at least what Original Medicare covers, but often add dental, vision, or hearing benefits.
  • You pay a monthly premium to the insurance company, use doctors in their network, and have an annual out-of-pocket spending limit that Original Medicare does not have.
  • Plans vary widely by location and insurer, so the same plan name may not be available where you live or may work differently in a different county.
  • You can switch plans or return to Original Medicare during the Annual Enrollment Period (October 15 to December 7 each year) or if you have a may have access to life event.

How Medicare Advantage Plans Cover Your Care

Every Medicare Advantage plan must cover at least the same services as Original Medicare: hospital stays, doctor visits, and preventive care. But each plan decides how much you pay out of pocket for each service. One plan might charge $15 to see your doctor; another might charge $40. One might cover physical therapy with no copay; another might limit it to 30 visits a year.

Most plans use a network model, meaning you pay less (or nothing) if you see a doctor who has signed a contract with that plan. If you see an out-of-network doctor, you pay more — sometimes much more. Some plans require you to pick a primary care doctor who coordinates your care and refers you to specialists. Others let you see any network doctor without a referral.

All Medicare Advantage plans have an annual out-of-pocket maximum. Once you reach it in a calendar year, the plan pays 100 percent of covered services for the rest of that year. Original Medicare has no such limit, which is why some people buy a separate Medigap policy to cover what Medicare does not.

Extra Benefits Medicare Advantage Plans Often Include

The main reason people choose Medicare Advantage is the extra coverage. Many plans include dental (cleanings, fillings, sometimes dentures), vision (eye exams, glasses, contacts), and hearing (exams and hearing aids). Some cover fitness programs, transportation to medical appointments, or over-the-counter medication allowances. A few cover acupuncture, chiropractic care, or podiatry.

These extras vary dramatically. One plan might cover two dental cleanings a year with no copay; another might cover one cleaning and charge $50. One might cover hearing aids up to $2,000 per ear; another might cover none. You have to read the plan's Summary of Benefits and Coverage document to know exactly what is included.

The catch: these benefits are only available through that specific plan. If you switch plans next year, your new plan may not offer the same benefits, or it may offer them differently. If you rely on a benefit — say, dental work or hearing aids — switching plans could mean losing it or paying out of pocket.

Costs: Premiums, Copays, and Deductibles

Medicare Advantage plans charge a monthly premium, which you pay to the insurance company. Many plans have a $0 premium, meaning you pay nothing extra beyond your Part B premium. But some charge $50 to $200 or more per month. The premium is separate from what you pay when you use care.

When you see a doctor or use a service, you pay a copay (a flat fee like $15) or coinsurance (a percentage of the cost). You also pay a deductible before the plan starts paying. Some plans have no deductible; others have one of $500 or more. These costs vary by plan and by service — your hospital deductible might be different from your doctor visit deductible.

All these costs — premiums, copays, deductibles, and coinsurance — count toward your annual out-of-pocket maximum. Once you hit that limit, the plan pays everything else for the year. The maximum varies by plan but is set by Medicare each year.

Network Restrictions and Referrals

Most Medicare Advantage plans are Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). HMOs have smaller networks and usually require a primary care doctor and referrals to see specialists. PPOs have larger networks and usually let you see specialists without a referral, but you pay more for out-of-network care.

If you travel or move, network restrictions matter. An HMO plan in your county may not cover doctors in the next county. If you spend winters in Florida and summers in Maine, an HMO tied to one state will not work. A PPO gives you more flexibility, but you pay higher copays and coinsurance for out-of-network doctors.

Before you join a plan, check whether your current doctors are in the network. If your doctor is not in the plan, you can either switch doctors or choose a different plan. Some people find out too late that their specialist is out of network and have to pay full price or switch plans mid-year (which is usually not allowed).

When You Can Join or Switch Plans

You can join a Medicare Advantage plan when you first turn 65 and sign up for Medicare. After that, you can only switch plans during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect January 1.

If you have a may have access to life event — you move out of the plan's service area, you lose employer coverage, you become may be able to access for Medicaid, or a few other situations — you may be able to switch outside the enrollment period. You have 60 days from the event to make the change. Contact Medicare at 1-800-MEDICARE to ask whether your situation qualifies.

If you want to drop your Medicare Advantage plan and go back to Original Medicare, you can do so during the Annual Enrollment Period. If you switch back to Original Medicare, you have 63 days to buy a Medigap policy. After that window closes, insurers can deny you or charge you more based on your health history.

Medicare Advantage vs. Original Medicare: The Trade-Offs

Medicare Advantage offers extra benefits and an out-of-pocket spending cap, which appeals to people who use a lot of care or want dental and vision coverage. But it comes with network restrictions, referral requirements, and the risk that your doctor or preferred hospital might not be in the plan next year.

Original Medicare has no network — you can see any doctor who accepts Medicare anywhere in the country. But it does not cover dental, vision, or hearing, and it has no out-of-pocket maximum. Many people on Original Medicare buy a Medigap policy to fill the gaps, which adds another monthly premium.

There is no universally "better" choice. It depends on your health, your doctors, whether you need dental or vision care, and how much you are willing to pay upfront versus when you use care. Some people switch back and forth depending on their circumstances.

Frequently Asked Questions

Can I keep my current doctor if I join a Medicare Advantage plan?

Only if your doctor is in that plan's network. Before you join, ask your doctor's office whether they accept that specific plan. If your doctor is not in the network, you can either choose a different plan or stay on Original Medicare.

What happens if I move to a different state?

Most Medicare Advantage plans are only available in specific counties or states. If you move, your current plan may not be available where you move to. You can switch to a different plan during the Annual Enrollment Period, or you may be able to switch when ready if your move qualifies as a life event.

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

Yes. You pay your Part B premium to Medicare, and then you may also pay a premium to the Medicare Advantage plan itself. Some plans have no additional premium, but you still owe Part B.

What if I need care from a doctor outside the network?

In an emergency, most plans cover out-of-network care. For non-emergency care, you pay more — sometimes the full cost. Some PPO plans cover out-of-network care at a higher copay. Check your plan's rules before you see an out-of-network doctor.

Can I use my Medicare Advantage plan if I travel?

It depends on the plan. HMOs usually only cover care in their service area. PPOs cover out-of-network care at a higher cost. If you travel frequently or live part-time in multiple states, ask the plan whether it covers care where you travel and what you will pay.