Medicare Advantage Plans
Medicare Advantage, also called Medicare Part C, is an alternative way to receive Medicare-covered services through a private insurance company approved by Medicare. Plan benefits, provider networks, costs, and availability vary by plan and location.
What Is Medicare Advantage?
Medicare Advantage is an alternative to Original Medicare in which a Medicare-approved private insurance company delivers your Part A and Part B benefits. Beneficiaries who enroll in Medicare Advantage remain enrolled in Medicare and must generally continue paying the Medicare Part B premium in addition to any plan premium.
Medicare Advantage plans are required to cover at least the same services as Original Medicare, with the exception of hospice care, which is still covered by Original Medicare. Many plans bundle additional benefits beyond Original Medicare coverage — the specific benefits, limitations, and networks are defined in each plan's Evidence of Coverage.
Plan availability, premiums, provider networks, cost-sharing structures, and benefits vary significantly by county and plan. Not all plans are available in all areas. We help Medicare-eligible individuals review what is available in their zip code during their applicable enrollment period.
Key Features of Medicare Advantage
Medicare Advantage plans vary widely. The following describes how these plans generally work — specific plan terms, limitations, and network rules are defined in each plan's Evidence of Coverage document.
Part A & Part B Coverage
Medicare Advantage plans provide your Part A hospital coverage and Part B medical coverage through the plan. You remain enrolled in Medicare, but the Medicare Advantage plan administers your covered Part A and Part B services under the plan's rules, network, and cost-sharing structure.
Prescription Drug Coverage
Most Medicare Advantage plans include Part D prescription drug coverage, often called MAPD plans. Not every Medicare Advantage plan includes drug coverage. Whether you can enroll in a separate Part D plan depends on the type of Medicare Advantage plan you have. For example, you generally cannot add a standalone Part D plan to an HMO or PPO that does not include drug coverage. Certain Private Fee-for-Service (PFFS) plans without drug coverage and Medicare Medical Savings Account (MSA) plans can use separate Part D coverage. Formularies, drug tiers, pharmacy networks, and cost sharing vary by plan.
Additional Benefits
Some plans may offer benefits beyond Original Medicare, such as routine dental, routine vision, routine hearing, fitness programs, or transportation — depending on the plan. These additional benefits vary significantly by plan and may have their own networks, eligibility rules, limitations, or separate vendors. Benefits are not guaranteed year to year.
Part B Premium
Members enrolled in Medicare Advantage generally continue paying the standard Medicare Part B premium. Some plans have a $0 plan premium beyond the Part B premium; others charge an additional premium. Some plans may offer a Part B premium reduction — rules and eligibility for this feature vary.
Plan Network Types
Plans may be structured as HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), PFFS (Private Fee-for-Service) plans, SNPs (Special Needs Plans), or other types. Network structure affects which providers you can see, whether referrals are required, and what you pay for out-of-network care. Review the plan's network before enrolling.
Out-of-Pocket Costs
Medicare Advantage plans have an annual limit on what you pay for covered Part A and Part B services. Once you reach the applicable plan limit, you pay nothing for covered Part A and Part B services for the rest of that year. The limit and how in-network and out-of-network costs are treated vary by plan type. Prescription drug costs and many supplemental benefits have separate cost-sharing rules and are not necessarily included in this medical out-of-pocket limit. Review the Summary of Benefits and Evidence of Coverage carefully.
Prior Authorization
Prior authorization, referral requirements, and step therapy may apply to certain services and medications. A service covered under Original Medicare may still require prior authorization from a Medicare Advantage plan before it will be covered. Review the plan's prior authorization requirements before enrolling.
Emergency & Urgently Needed Care
Medicare Advantage plans are required to cover emergency care and urgently needed care regardless of where you are in the United States. Out-of-area and international emergency coverage rules vary by plan. Review the plan's emergency and travel provisions, especially if you spend time in multiple locations.
Evaluating Medicare Advantage Plans
No single plan is the right fit for everyone. When comparing Medicare Advantage plans, consider reviewing the following factors against your personal healthcare needs, providers, and budget.
- Doctors and hospitals: Confirm that your current providers are in the plan's network and are accepting new patients under that plan.
- Prescription drugs and pharmacy network: If the plan includes drug coverage, verify your current medications are on the formulary and at what tier, and that your preferred pharmacy is in-network.
- Monthly premium: The plan premium in addition to your Part B premium.
- Deductibles, copays, and coinsurance: Review cost-sharing for the services you use most — doctor visits, specialists, hospital stays, and procedures.
- Annual out-of-pocket maximum: The most you would pay in a year for covered Part A and Part B services before the plan covers those costs in full. The limit and how it is calculated vary by plan type — drug costs and many supplemental benefits are generally not included in this same limit.
- Network type: Whether the plan is an HMO, PPO, or another structure, and what that means for your provider choices and out-of-network costs.
- Referral and authorization requirements: Whether you need a referral to see a specialist and which services require prior authorization.
- Travel and out-of-area coverage: How the plan handles care when you are outside the service area.
- Extra benefits and their limitations: If the plan offers dental, vision, hearing, or other benefits — review what is actually covered, what is excluded, network limitations, and annual maximums before relying on these benefits.
What to Keep in Mind
- A provider who accepts Medicare does not automatically accept every Medicare Advantage plan. Confirm network participation with your provider directly each year.
- Plan benefits, premiums, and networks can change each year. Review your plan's Annual Notice of Change every fall during the Annual Enrollment Period.
- Extra benefits may have their own networks, eligibility rules, annual limits, or separate vendors. They are not always as comprehensive as traditional standalone coverage.
- Medicare Advantage plan availability varies by county. A plan available in one location may not be available in another.
- If you leave Medicare Advantage and return to Original Medicare, you may not automatically have a guaranteed right to buy every Medigap policy. Depending on your timing, circumstances, and state rules, medical underwriting may apply. Review your Medigap rights before making the change.
When You Can Enroll in Medicare Advantage
Enrollment in Medicare Advantage is generally limited to specific periods defined by Medicare. Eligibility and effective dates depend on your individual circumstances.
Initial Enrollment Period (IEP)
A 7-month window centered around your 65th birthday — three months before, the month of, and three months after. This is generally the first opportunity to enroll in Medicare Advantage if you are becoming eligible for Medicare.
Annual Enrollment Period (AEP)
October 15 – December 7 each year. During AEP, Medicare beneficiaries can switch between Original Medicare and Medicare Advantage, change Medicare Advantage plans, or make changes to Part D drug coverage. Changes generally take effect January 1 of the following year.
Medicare Advantage Open Enrollment Period
January 1 – March 31 each year. Individuals already enrolled in a Medicare Advantage plan can switch to a different Medicare Advantage plan or return to Original Medicare (and join a standalone Part D plan) during this period.
Special Enrollment Periods (SEPs)
Certain qualifying events — such as moving to a new service area, losing other coverage, qualifying for a low-income subsidy program, or a plan leaving your area — may trigger a Special Enrollment Period. The specific SEP available, its duration, and what changes it permits depend on the qualifying event and your circumstances.
Medicare Advantage — Frequently Asked Questions
Is Medicare Advantage the same as Original Medicare?
No. Original Medicare is managed directly by the federal government (CMS) and consists of Part A (hospital) and Part B (medical). Medicare Advantage is an alternative way to receive those same benefits through a Medicare-approved private insurance company. You remain enrolled in Medicare when you have Medicare Advantage — the plan delivers your Part A and Part B benefits rather than Original Medicare paying providers directly. Plan rules, networks, and costs differ significantly from Original Medicare.
Can I keep my doctor with Medicare Advantage?
It depends on the plan. Medicare Advantage plans typically have provider networks, and whether your current doctor is in a plan's network determines whether — and at what cost — you can continue seeing them under that plan. A doctor who accepts Original Medicare does not automatically accept every Medicare Advantage plan. Before enrolling in any plan, confirm that your current providers participate in that plan's network and are accepting new patients. Network participation can also change from year to year.
Does every Medicare Advantage plan include drug coverage?
No. Most Medicare Advantage plans include Part D prescription drug coverage, often called MAPD plans, but not all do. Whether you can add a separate Part D plan depends on the type of Medicare Advantage plan. In general, you cannot add standalone Part D coverage to an HMO or PPO that does not include drug coverage. Certain PFFS plans without drug coverage and MSA plans can use a separate Part D plan. If your Medicare Advantage plan includes drug coverage, review its formulary, drug tiers, pharmacy network, and cost sharing carefully.
Can I change my Medicare Advantage plan later?
Generally, you can make changes during Medicare's defined enrollment periods — primarily the Annual Enrollment Period (October 15 – December 7) and the Medicare Advantage Open Enrollment Period (January 1 – March 31). Outside these periods, changes are usually limited to situations where a qualifying Special Enrollment Period applies. Review your plan's Annual Notice of Change each fall and compare available options before the Annual Enrollment Period closes.
Do I still pay the Medicare Part B premium with Medicare Advantage?
Generally, yes. Beneficiaries enrolled in Medicare Advantage must continue to pay the Medicare Part B premium, which is set by CMS and may change each year. Some Medicare Advantage plans charge an additional plan premium on top of the Part B premium; others have a $0 plan premium. Some plans may offer a partial reduction of the Part B premium — the availability and rules for this feature vary by plan and are subject to Medicare regulations. Your overall cost includes the Part B premium, any plan premium, and plan cost-sharing for services you use.
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Questions About Medicare Advantage?
Our licensed agents help Medicare-eligible individuals review available plan options in their area — personally, at no obligation.
We do not offer every plan available in your area. We are licensed insurance agents and can help you review Medicare plan options available through the insurance carriers we represent. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.
We are not connected with or endorsed by the U.S. government or the federal Medicare program. Plan availability, benefits, premiums, copayments, provider networks, formularies, and eligibility requirements may vary by plan, service area, and year.