Understanding Medicare Advantage (Part C)
Medicare Advantage plans are an alternative way to get your Medicare benefits. Learn how they work and what to consider when choosing a plan.
Stay Current with Policy Changes
Medicare policies and regulations change frequently. For the most up-to-date information, always check official sources like Medicare.gov or consult with a licensed insurance agent.
Quick Facts: 2025-2026 Changes
Drug Costs:
Cap at $2,000 (2025) → $2,100 (2026) under IRA reforms
Open Enrollment:
Oct 15–Dec 7 (changes effective Jan 1). MA-OEP: Jan 1–Mar 31 (one change)
How Medicare Advantage Works
Private Insurance Plans
Medicare Advantage plans are offered by private insurance companies that contract with Medicare to provide Part A and Part B benefits.
Network-Based Coverage
Most plans have provider networks. You typically pay less when using in-network doctors, hospitals, and other healthcare providers.
Annual Enrollment Period
You can join, switch, or drop a Medicare Advantage plan during the Annual Enrollment Period (October 15 - December 7). Changes take effect January 1.
Types of Medicare Advantage Plans
HMO (Health Maintenance Organization)
Usually require you to use doctors, hospitals, and other providers in the plan's network. You may need a referral to see a specialist.
Cost: Generally lower premiums and out-of-pocket costs, but less flexibility in choosing providers.
PPO (Preferred Provider Organization)
Allow you to see any doctor or specialist without a referral, but you pay less when using in-network providers.
Cost: Higher premiums than HMOs, but more flexibility in choosing healthcare providers.
PFFS (Private Fee-for-Service)
Determine how much they will pay doctors, other healthcare providers, and hospitals, and how much you must pay.
Cost: Varies by plan. You may pay more or less than with Original Medicare.
SNP (Special Needs Plans)
Designed for people with specific diseases or characteristics. These plans tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.
Cost: Varies by plan and specific needs covered.
What Medicare Advantage Plans Cover
Always Included
- All Part A and Part B benefits
- Emergency and urgent care
- Prescription drug coverage (most plans)
Often Included
- Vision, hearing, and dental benefits
- Fitness programs and wellness benefits
- Transportation to medical appointments
Important Considerations
Provider Networks
Check if your current doctors and hospitals are in the plan's network. Going out-of-network can significantly increase your costs.
Prescription Drug Coverage
Most Medicare Advantage plans include prescription drug coverage. Make sure your medications are covered and check the cost-sharing requirements.
Prior Authorization
Some plans require prior authorization for certain services or medications. This means you need approval from the plan before receiving the service.
Maximum Out-of-Pocket Limits
Medicare Advantage plans have annual maximum out-of-pocket limits. Once you reach this limit, the plan pays 100% of covered services for the rest of the year.
Stay Current with Medicare Information
Official Sources
- Medicare.gov - Official Medicare website
- CMS.gov - Centers for Medicare & Medicaid Services
- SSA.gov - Social Security Administration
Get Personalized Help
- 1-800-MEDICARE - Call for help with Medicare questions
- State Health Insurance Assistance Program (SHIP) - Free, unbiased counseling
- Licensed Insurance Agents - Get help comparing plans in your area
Important: This information is for educational purposes only. Medicare policies and regulations change frequently. Always verify current information with official sources or consult with a licensed insurance professional before making decisions about your Medicare coverage.