Medicare Advantage, Explained Clearly.
Medicare Advantage is another way to receive your Medicare Part A and Part B benefits through a Medicare-approved private insurance company. Plans differ by location, carrier, network, costs, prescription coverage, and additional benefits, so understanding the details matters.
What Is Medicare Advantage?
An alternative way to receive your Medicare-covered services.
Medicare Advantage, also called Medicare Part C, is an alternative way to receive Medicare-covered Part A and Part B services. Medicare Advantage plans are offered by private insurance companies approved by Medicare.
To join a Medicare Advantage plan, you generally must have both Medicare Part A and Part B and meet the plan's eligibility and service-area requirements.
Original Medicare
Administered by the federal government
Part A
Part B
Medicare Advantage
Offered by Medicare-approved private plans
Part A and Part B coverage delivered through a Medicare-approved private plan.
Medicare Advantage does not replace your Medicare entitlement — it is a different way to receive your Medicare-covered Part A and Part B benefits.
What Can a Medicare Advantage Plan Include?
Coverage varies by plan — review the details, not just the headline.
Medicare Part A Services
Hospital-related Medicare-covered services.
Medicare Part B Services
Physician and outpatient Medicare-covered services.
Prescription Drug Coverage
Most Medicare Advantage plans include Medicare Part D prescription drug coverage.
Additional Benefits
Some Medicare Advantage plans may offer additional benefits that Original Medicare does not cover. Examples may include certain dental, vision, hearing, fitness, transportation, over-the-counter, or other supplemental benefits.
Benefits and availability vary by plan, carrier, service area, and eligibility. Not every plan includes these benefits.
Don't Compare a Plan by One Benefit Alone.
A plan may look attractive because of one advertised benefit, but Medicare coverage should be reviewed as a complete package.
Your Doctors
Are your preferred doctors, specialists, hospitals, and other providers in the plan's network?
Your Prescriptions
Are your medications on the plan's formulary, and what coverage rules or cost sharing may apply?
Your Pharmacy
Are your preferred pharmacies in the plan's network, and does the plan offer preferred pharmacy pricing?
Your Costs
Review applicable premiums, deductibles, copayments, coinsurance, and maximum out-of-pocket amounts.
Your Network
Understand whether the plan uses a network and what may happen when receiving non-emergency care outside that network.
Prior Authorization
Some plans may require approval before covering certain services or supplies.
Referrals
Referral requirements may vary depending on the type of plan.
Additional Benefits
Review what is actually included, the limitations, and how the benefit works.
Common Types of Medicare Advantage Plans
HMO
Health Maintenance Organization
HMO plans generally use a provider network for covered care, with certain exceptions such as emergency or urgent care. Referral requirements may apply.
PPO
Preferred Provider Organization
PPO plans have provider networks, but members can generally receive covered services outside the network at a higher cost, subject to the plan's rules.
SNP
Special Needs Plan
Special Needs Plans are Medicare Advantage plans designed for people who meet specific eligibility criteria, such as certain chronic conditions, institutional status, or eligibility for both Medicare and Medicaid.
Other types of Medicare Advantage plans may also be available depending on the area.
Your Doctors Matter.
A benefit package only works well if the plan also works with the care you actually use. Network rules vary by plan type.
Key things to review:
- Primary care physician
- Specialists
- Hospitals
- Outpatient facilities
- Preferred pharmacies
- Other important providers
Provider participation can change and should be verified using current plan information. Ike can help you review whether your preferred doctors and providers participate in available plan networks.
Don't Forget Your Prescriptions.
Most Medicare Advantage plans include Medicare drug coverage. Each drug plan has a formulary, or list of covered drugs, and plans may apply different cost-sharing levels and coverage rules.
Key things to review:
- Exact medication
- Dosage
- Formulary status
- Pharmacy
- Tier / cost sharing
- Prior authorization where applicable
- Quantity limits where applicable
- Step therapy where applicable
Your Medications, Reviewed
Ike can help you understand how your current prescriptions may be covered under available Medicare Advantage drug options in your area.
What Could I Pay?
Your costs depend on the specific plan and the services you use.
- Medicare Part B premium obligations
- Medicare Advantage plan premium, if any
- Deductibles, if applicable
- Copays
- Coinsurance
- Prescription drug costs
- Maximum out-of-pocket amount for applicable Part A and Part B services
Some Medicare Advantage plans may have a $0 plan premium, but a $0 premium does not mean all health care or prescription costs are $0. Availability varies by plan and area.
Maximum Out-of-Pocket Protection
Medicare Advantage plans have an annual limit on what you pay out of pocket for covered Part A and Part B services. The specific limit and costs vary by plan.
Review the plan's current materials for the applicable out-of-pocket limit and cost-sharing details.
Understand the Plan Rules
Plan rules vary. Understanding them before enrollment can help you know how to access covered care.
Depending on the plan and service, a Medicare Advantage plan may require prior authorization before certain services or supplies are covered.
Medicare Advantage and Medicare Supplement Are Not the Same Thing.
Medicare Advantage
A way to receive Medicare-covered Part A and Part B services through a Medicare-approved private plan.
Medicare Supplement / Medigap
Private insurance designed to work with Original Medicare and help pay certain out-of-pocket costs.
You generally cannot use a Medicare Supplement policy to cover Medicare Advantage cost sharing.
Is Medicare Advantage Worth Exploring?
The answer depends on your individual needs, providers, prescriptions, budget, location, and coverage preferences.
Health Coverage Isn't Always the Whole Financial Story.
Medicare Advantage and supplemental insurance products such as cancer, critical illness, or hospital indemnity coverage are separate types of insurance. Depending on the policy, separate supplemental coverage may help address certain financial exposures associated with covered events.
Let's Look at the Whole Plan — Not Just the Ad.
As an independent licensed insurance broker, Ike can help you review available Medicare options from multiple insurance carriers he represents.
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Frequently Asked Questions
Quick answers to questions many people have about Medicare Advantage.
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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE for information on all of your options.