What Medicare Advantage is
Medicare Advantage is also called Part C. These plans are offered by private insurance companies that are approved by Medicare. When you join one, the plan provides your Part A (hospital) and Part B (medical) coverage instead of Original Medicare.
A few things stay the same:
- You still have Medicare. You keep your rights and protections.
- You still pay your Part B premium, unless someone else, like Medicaid, pays it for you.
- If you need hospice care, Original Medicare covers it, even while you're in a Medicare Advantage plan.
To join, you need Part A and Part B, and you must live in the plan's service area. Plans and costs are different from county to county.
How networks work
Most Medicare Advantage plans have a network. A network is the group of doctors, hospitals, and other providers the plan works with. The two most common types are HMO and PPO plans.
HMO plans
- You generally need to use doctors and hospitals in the plan's network.
- If you go outside the network, the plan usually won't pay, except for emergencies and urgent care.
- Many HMO plans ask you to pick a primary care doctor and get a referral before you see a specialist.
PPO plans
- You can see doctors in the network or outside it.
- You usually pay less when you stay in the network.
- You generally don't need a referral to see a specialist.
Networks can change. A doctor who is in a plan's network this year may not be next year. That's one reason I check your doctors every fall.
What's often included
Most Medicare Advantage plans include Part D prescription drug coverage. These are sometimes called MAPD plans.
Some plans may also include benefits that Original Medicare doesn't cover, such as:
- Routine dental care
- Eye exams and glasses
- Hearing exams and hearing aids
- Fitness programs
These extra benefits vary by plan and county. What's covered, how much, and what you pay are all different from one plan to the next. Some plans may limit them to certain providers. I'll show you exactly what each plan you're considering includes.
Costs to understand
When you compare plans, look at the whole picture, not just one number.
- Premium. Some plans charge a monthly premium. This is in addition to your Part B premium.
- Copays and coinsurance. These are what you pay when you get care, like a doctor visit or a hospital stay. A copay is a set amount. Coinsurance is a percentage of the cost.
- Deductibles. Some plans have a deductible you pay before the plan starts to pay its share.
- Maximum out-of-pocket limit. Every Medicare Advantage plan has a yearly limit on what you pay for covered Part A and Part B services. Once you reach it, the plan pays for covered services for the rest of the year. The limit varies by plan. Drug costs are counted separately.
Special Needs Plans
Special Needs Plans, or SNPs, are Medicare Advantage plans for people with certain needs. Benefits, doctors, and drug lists are designed around those needs.
- D-SNP (Dual Eligible). For people who have both Medicare and Medicaid.
- C-SNP (Chronic Condition). For people with certain long-term conditions, such as diabetes or chronic heart failure.
There is also a type for people who live in a nursing home or need that level of care. If you think you may qualify for a Special Needs Plan, I can check what's available in your county.
Comparing your two main choices
This is a general comparison. Every plan is different, so we'll look at the details of the plans available to you.
| Topic | Medicare Advantage | Original Medicare plus a Supplement |
|---|---|---|
| Doctor choice | Usually a network of doctors and hospitals. PPO plans may cover out-of-network care at a higher cost. | Any doctor or hospital in the U.S. that accepts Medicare. |
| Referrals | Many HMO plans require a referral to see a specialist. PPO plans usually don't. | No referrals needed. |
| Out-of-pocket limit | Yes. Each plan has a yearly limit for covered Part A and Part B services. | Original Medicare has no yearly limit. A Supplement can cover most or all of the gaps, depending on the plan. |
| Drug coverage | Included in most plans. | Not included. You'd add a separate Part D plan. |
| Extra benefits | Some plans may include dental, vision, hearing, or fitness benefits. These vary by plan and county. | Generally not included. You could buy separate dental or vision coverage. |
| Travel | Emergency and urgent care are covered anywhere in the U.S. Routine care outside the network or service area may not be covered. | Covered with any provider in the U.S. that accepts Medicare. Some Supplement plans help with emergency care outside the country, up to plan limits. |
| Monthly costs | Part B premium, plus the plan's premium if it has one. | Part B premium, plus a Supplement premium and a Part D premium. |
Who it may suit, and the tradeoffs
Medicare Advantage may suit you if you're comfortable using a network, you like having your drug coverage in the same plan, and you'd like a yearly limit on what you pay for medical care.
There are tradeoffs to think about:
- Networks. Your doctors need to be in the plan's network, or you may pay more or have no coverage.
- Approval in advance. Some services may need the plan's approval first. This is called prior authorization.
- Costs when you use care. You pay copays or coinsurance as you go, up to the yearly limit.
- Yearly changes. Plans can change their benefits, costs, and networks each year.
- Switching later. If you leave Medicare Advantage for Original Medicare later, you may not be able to buy a Medicare Supplement plan without answering health questions. In Georgia, a company can turn you down or charge more based on your health in that case. There's an exception: if you joined a Medicare Advantage plan when you first became eligible at 65 and leave it within 12 months, you can buy a Medicare Supplement without health questions. Read how Supplement enrollment works.
You can only be in one Medicare Advantage plan at a time. And you can't use a Medicare Supplement plan with a Medicare Advantage plan.
How I help you compare
I start with what matters to you. Then I do the checking for you.
- I check whether your doctors and hospitals are in each plan's network.
- I check your prescriptions against each plan's drug list and estimate what you'd pay.
- I explain the premium, copays, and out-of-pocket limit for each plan side by side.
- I tell you plainly what each plan doesn't cover.
I can compare plans from the insurance companies I represent. Not every company offers every type of plan or serves every county, so which plans are available depends on where you live. For information on all of your options, you can also visit Medicare's plan finder.