Medicare Advantage plans offer you another way to use your Medicare benefits – and usually provide extras, like prescription drug coverage and routine dental care.
Medicare Advantage (also called Part C) doesn't exactly replace Original Medicare, because you still need Medicare Parts A and B to join a Medicare Advantage plan. And, of course, you still have to pay your Part B premium.
Instead, a Medicare Advantage plan is more like another way to access your Medicare benefits. Your coverage gets bundled into a single plan, similar to what you likely had through an employer. And, like those insurance plans, Part C usually covers items like routine dental and vision care, prescriptions, and even gym memberships - coverage you don't get with Original Medicare.
What is Medicare Advantage?
Medicare Advantage plans are offered through Medicare-approved private insurers, who must follow rules set by the Centers for Medicare & Medicaid Services (CMS).
The majority of Part C plans, around 90%, include prescription drug coverage (Medicare Part D), and most also offer additional benefits like dental, hearing, and vision services.
Advantage plans also have a maximum out-of-pocket limit (MOOP) – something you don’t get with Original Medicare. CMS sets the limit, which is $8,300 in 2023. However, most Advantage plans have a lower MOOP, so be sure to include that when you’re comparing your options.
Medicare Advantage plan types
The most common types of Medicare Advantage plan are:
- Health Maintenance Organization (HMO) plans: In an HMO plan, your health care services typically must be performed by a provider within the plan's network for coverage to apply. There are exceptions for out-of-area urgent care, temporary out-of-area dialysis, and emergency care.
- Preferred Provider Organization (PPO) plans: A PPO plan operates on a network of doctors and facilities, but also allows you to see out-of-network providers for covered services at a higher cost. Emergency and urgent care are always covered in PPO plans.
- Private Fee-for-Service (PFFS) plans: When you have a PFFS plan, the plan decides how much it will pay for health care services and how much you will pay when you seek care. Most PFFS plans have a network of providers, but some allow you to see providers outside the network at a higher cost.
- Special Needs plans (SNPs): These plans are limited to people with specific characteristics or diseases, and SNPs build their benefits, formularies, and networks around this. Not all SNPs cover out-of-network services, but some do.
The type of Medicare Advantage plan you choose should be based on your specific health care needs, regardless of whether you need an SNP. You want to make sure your plan fits your life, in everything from cost to the providers you can see.
What is Original Medicare?
Original Medicare is made up of Medicare Part A and Part B. Part A generally covers inpatient hospital care, home health services, hospice care, and some nursing care. Part B covers outpatient services, such as doctor visits, preventive screenings, lab work, mental health care, and some vaccines.
Neither part of Original Medicare covers prescription medications; that requires a Part D prescription drug plan, which you can get as either a standalone plan or through a Medicare Advantage Prescription Drug plan (MA-PD). If your prescription drug coverage is not provided by Medicare, you need to make sure it is “creditable” to avoid late enrollment penalties when you do decide to join a Part D plan. Generally speaking, that means your insurance plan provides comparable benefits for a comparable price to Medicare. Prescription discount programs do not qualify as “creditable.”
Original Medicare also rarely covers services vision or dental care.
What does Medicare Advantage cover?
Medicare Advantage plans have to cover everything Original Medicare does, but most offer additional coverage. In fact, over 90% of MA plans cover:
- Prescription drugs
- Gym and fitness benefits
- Routine dental services
- Routine vision care
- Hearing aids
While most Part C plans include drug coverage, not all of them do. If you need an Advantage plan that covers medications, be sure to thoroughly review the coverage of prospective plans.
It is important to note that you cannot have both a standalone Part D plan and MA-PD plan. If you try to sign up for a standalone Part D plan while enrolled in an Advantage plan, you will be placed back in Original Medicare.
What does Medicare Advantage cost?
Costs for Medicare Advantage plans vary depending on the plan and insurer you choose. In general, though, MA costs may include:
- A monthly premium
- The yearly deductible
- Co-pays or co-insurance
- Annual out-of-pocket max
Nearly 70% of Advantage plans have no monthly premium, but the average is around $18 per month.
Please note that, even if your Part C plan has a monthly premium, you still have to pay your Part B premium.
Can you keep Medigap with Medicare Advantage?
In short, no, you can't have a Medicare Supplement plan (also known as Medigap) and Medicare Advantage at the same time. But you also don't need it, since Medigap can't be used to cover any of the costs you have with a Medicare Advantage plan. It is actually illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage plan, unless you are returning to Original Medicare. Our Ultimate Guide to Medigap answers all your Medicare Supplement questions.
When can you join a Medicare Advantage plan?
There are a few times you can sign up for a Medicare Advantage plan:
- Annual Enrollment Period (AEP): From October 15 through December 7, you can make just about any change you want to your current Medicare coverage, including joining or switching to a new MA or Part D plan.
- Medicare Advantage Open Enrollment Period (OEP): If you are currently enrolled in a Medicare Advantage plan, from January 1 through March 31 every year you can switch Part C plans or go back to Original Medicare. You can only switch plans once during OEP. If making this change causes you to lose your prescription drug coverage, you may also join a standalone Part D plan.
- Initial Enrollment Period (IEP): Lasting a total of seven months, your IEP starts three months before the month of your 65th birthday, and lasts for three months after it.
- Special Enrollment Period (SEP): Outside of the above enrollment periods, you would need to qualify for an SEP to sign up for Medicare Advantage. Examples include leaving your plan's service area and no-fault coverage loss. Learn more about SEPs on Medicare.gov.
If you're ready to compare Medicare Advantage plans, the easiest way is with our Find a Plan tool. Simply enter your zip code and prescriptions, and you'll be comparing plans in no time.
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