What Medicare Advantage is
A Medicare Advantage plan is offered by a private insurance company under a contract with Medicare. When you enroll, the plan takes over administration of your Medicare Part A and Part B benefits and applies its own network rules, copayments, and coverage policies.
You do not give up Medicare by joining one of these plans. You remain in the Medicare program and continue to have Medicare rights and protections.
How it relates to Part A and Part B
To join a Medicare Advantage plan you generally need to have both Part A and Part B, and you generally continue paying your Part B premium. Some plans also charge their own monthly premium on top of that, and some do not.
Plans must cover the services Original Medicare covers, other than hospice care, which continues to be covered under Part A. What differs is how those services are delivered and what you pay when you use them.
Prescription drug coverage
Many Medicare Advantage plans include Part D prescription drug coverage in the same plan. These are often described as MAPD plans.
Some Medicare Advantage plans, particularly certain PPO and Private Fee-for-Service designs, do not include drug coverage. Enrollment rules about pairing a standalone Part D plan with a Medicare Advantage plan are strict, so it is worth confirming how a specific plan handles medications before enrolling.
Provider networks
Most Medicare Advantage plans use a network of contracted doctors, hospitals, pharmacies, and other providers. Care from providers inside the network usually costs less, and some plans cover non-emergency care only when it is received in network.
Networks are not permanent. Providers can join or leave a plan's network during the year, so confirming that your doctors participate is something to repeat rather than do once.
HMO and PPO plan structures
| Plan type | Provider access | Referrals | Out-of-network care |
|---|---|---|---|
| HMO | Care is generally coordinated within the plan's network | Often required to see a specialist | Usually covered only for emergency or urgent care, or dialysis away from home |
| PPO | In-network and out-of-network providers may both be available | Usually not required | Often covered at a higher cost share |
| Special Needs Plan (SNP) | Network built around a specific eligible population | Varies by plan | Varies by plan; eligibility requirements apply |
Plan types, rules, and availability vary by carrier and county. Review the plan's Evidence of Coverage for the rules that apply to a specific plan.
Possible additional benefits
Some Medicare Advantage plans offer benefits beyond what Original Medicare covers. Depending on the plan, that can include routine dental, vision, or hearing services, a fitness benefit, transportation to approved appointments, an over-the-counter allowance, or in-home support services.
These benefits are optional plan features, not Medicare entitlements. Two plans sold in the same county can differ substantially.
- Not every plan includes additional benefits.
- Availability and amounts vary by plan and location.
- Eligibility rules may apply.
- Benefits can change each plan year.
Premiums and cost sharing
Medicare Advantage costs generally include any plan premium, your Part B premium, and the copayments or coinsurance you pay when you receive care. Some plans have a low or zero plan premium and higher cost sharing; others reverse that balance.
Because cost sharing is service by service, the total you spend in a year depends heavily on how much care you actually use.
Maximum out-of-pocket limits
Medicare Advantage plans include an annual maximum out-of-pocket limit for covered Part A and Part B services. Once you reach that limit, the plan generally covers those services for the rest of the plan year.
The limit amount differs by plan, and prescription drug costs are tracked separately under Part D rules rather than counted toward the medical limit.
Who may consider a Medicare Advantage plan
- People whose current doctors participate in a plan's network
- People who prefer a lower monthly premium and are comfortable paying copays when they use care
- People who want medical and prescription coverage administered in a single plan
- People who value having an annual cap on covered medical costs
- People interested in supplemental benefits a specific plan happens to offer
Questions worth asking before you enroll
- Are my doctors, specialists, and preferred hospital in this plan's network today?
- Are each of my prescriptions on the formulary, and at what tier?
- What is the plan premium, and what will I still pay for Part B?
- What are the copays for primary care, specialists, imaging, and hospital stays?
- What is the maximum out-of-pocket limit this year?
- Do I need referrals, and what happens if I need care while traveling?
- Which supplemental benefits are actually included, and what are the eligibility rules?
Important disclosures
- Benefits vary by plan and location, and not every plan includes every additional benefit.
- You generally continue to pay your Medicare Part B premium.
- Provider networks and formularies can change.
- Enrollment depends on eligibility and on an applicable enrollment period. Enrollment is not guaranteed, and there is no obligation to enroll.
- Enrollment in a plan with a Medicare contract depends on contract renewal, where applicable.
- No specific benefit, savings, or outcome is guaranteed.
- Medicare evaluates plans based on a five-star rating system. Star Ratings are calculated each year and may change from one year to the next.
- We do not offer every plan available in your area. Any information we provide is limited to the plans Everlive Advisors LLC represents in your area.
- To learn about all of the options available to you, contact Medicare.gov, call 1-800-MEDICARE (TTY 1-877-486-2048), 24 hours a day, 7 days a week, or contact your local State Health Insurance Assistance Program (SHIP).
Frequently asked questions
- Do I still have Medicare if I join a Medicare Advantage plan?
- Yes. You remain enrolled in Medicare. A private plan administers your Part A and Part B benefits under a contract with Medicare, and you keep your Medicare rights and protections.
- Do I keep paying my Part B premium?
- Generally yes. Most people continue paying the Part B premium in addition to any premium the Medicare Advantage plan charges.
- Can I see any doctor I want?
- That depends on the plan. HMO plans generally limit non-emergency care to network providers, while PPO plans often cover out-of-network care at a higher cost share.
- Can a plan change its benefits?
- Yes. Benefits, networks, formularies, and costs can change each plan year, which is why reviewing your plan annually is worthwhile.
Talk through your Medicare options
Answer a few questions and a licensed insurance agent can help you review the Medicare options available where you live. There is no obligation to enroll.
By calling or submitting a form, you may be connected with a licensed insurance agent.
