What Is Medicare Advantage?

Medicare Advantage Explained in Plain English

Medicare Advantage is another way to receive your Medicare coverage. It is also called Medicare Part C.

Instead of getting your Medicare benefits directly through Original Medicare, you receive your Medicare-covered services through a private insurance company approved by Medicare. Medicare.gov explains that Medicare Advantage bundles your Part A, Part B, and usually Part D coverage into one plan.

This page is designed to help you understand what Medicare Advantage is, how it works, how it compares with Original Medicare, and what questions you may want to ask before choosing how to receive your Medicare coverage.

This page is educational only. We do not recommend any specific Medicare Advantage plan, insurance company, premium, doctor network, drug coverage, or plan benefit.

What Is Medicare Advantage?

Medicare Advantage is a type of Medicare health plan offered by a private insurance company approved by Medicare.

It is called Part C because it is another part of the Medicare program. To join a Medicare Advantage plan, you must have both Medicare Part A and Medicare Part B. Medicare.gov states that Medicare Advantage plans are sometimes called “Part C” or “MA plans,” and that most include Medicare drug coverage, also called Part D.

A simple way to remember it:

Medicare Advantage is an alternative way to receive your Medicare benefits through a Medicare-approved private insurance company.

Medicare Advantage does not mean you are leaving Medicare. You are still in the Medicare program, but your benefits are managed through the Medicare Advantage plan.

How Does Medicare Advantage Work?

With Medicare Advantage, a private insurance company approved by Medicare provides your Medicare-covered services.

Medicare Advantage plans must follow rules set by Medicare. They must cover all emergency and urgent care and almost all medically necessary services that Original Medicare covers. However, the way you receive care may be different because plans can have different rules, provider networks, referrals, prior authorization requirements, and costs.

That is one of the most important things to understand:

Medicare Advantage covers Medicare services, but the rules for receiving those services may be different from Original Medicare.

For example, you may need to use certain doctors or hospitals in the plan’s network, and some services may require approval before the plan covers them.

Medicare Advantage vs. Original Medicare

Most people receive Medicare coverage in one of two main ways:

  1. Original Medicare

  2. Medicare Advantage

Original Medicare includes Part A and Part B. With Original Medicare, you can generally use any doctor or hospital that accepts Medicare anywhere in the United States. You may also choose to add a separate Part D prescription drug plan and may choose to buy Medicare Supplement Insurance, also called Medigap.

Medicare Advantage is different. With Medicare Advantage, you usually receive your Medicare-covered services through the plan’s network and service area. Some plans may cover certain out-of-network services, but usually at a higher cost.

A simple comparison:

Original Medicare
Part A + Part B
Optional Part D
Optional Medigap

Medicare Advantage
Part C
Private Medicare-approved plan
Usually includes Part D
Uses plan rules and networks

This page is not here to say one path is better than the other. The goal is to help you understand how the two paths are structured.

Do You Still Have Medicare With Medicare Advantage?

Yes.

This is one of the most common misunderstandings about Medicare Advantage.

If you join a Medicare Advantage plan, you are still in Medicare. You still must have Medicare Part A and Part B to join, and you generally must continue paying your Medicare Part B premium. Medicare.gov explains that Medicare Advantage is another way to get your Part A and Part B benefits instead of Original Medicare.

A simple way to say it:

Medicare Advantage does not replace Medicare. It changes how you receive your Medicare benefits.

Do You Still Pay the Part B Premium?

Yes, in most cases you still pay your Medicare Part B premium if you join a Medicare Advantage plan.

Medicare.gov explains that with Medicare Advantage, you pay the monthly Part B premium and may also have to pay the plan’s premium, depending on the plan.

This is important because some people mistakenly believe Medicare Advantage makes the Part B premium go away. It generally does not.

A simple reminder:

To have Medicare Advantage, you must have Part A and Part B, and you generally continue paying the Part B premium.

What Does Medicare Advantage Cover?

Medicare Advantage plans must cover almost all medically necessary services that Original Medicare covers. Plans must also cover emergency and urgent care.

Many Medicare Advantage plans also include Medicare prescription drug coverage, also called Part D. Medicare.gov explains that Medicare Advantage plans usually include Part D coverage.

Some plans may offer additional features beyond Original Medicare, but those details vary by plan, location, and year. Because this page is educational, we are not comparing specific extra benefits, plan details, or insurance companies.

The key point is:

Medicare Advantage must cover core Medicare services, but each plan may work differently.

Medicare Advantage and Prescription Drug Coverage

Many Medicare Advantage plans include prescription drug coverage.

When a Medicare Advantage plan includes drug coverage, you usually receive your Part A, Part B, and Part D coverage through one plan. Medicare.gov explains that you generally get your drug coverage through the Medicare Advantage plan if it includes Part D.

This matters because you usually should not add a separate Part D drug plan to a Medicare Advantage plan that already includes drug coverage unless you are in a plan type that allows it. Medicare.gov warns that joining a separate drug plan in certain situations can cause you to be disenrolled from your Medicare Advantage plan and returned to Original Medicare.

Before choosing coverage, it is important to understand:

  • Whether prescription drug coverage is included

  • Whether your medications are covered

  • What pharmacy rules may apply

  • What your estimated drug costs may be

Medicare Advantage and Doctor Networks

Doctor and hospital access is one of the biggest differences between Original Medicare and Medicare Advantage.

With Original Medicare, you can generally use any doctor or hospital that takes Medicare anywhere in the United States. With Medicare Advantage, you may need to use doctors and other providers in the plan’s network and service area for non-emergency care. Some plans may cover out-of-network care, but typically at a higher cost.

Before choosing a Medicare Advantage plan, it is important to ask:

  • Are my doctors in the plan’s network?

  • Are my preferred hospitals in the network?

  • Are my pharmacies in the network?

  • What happens if I need care while traveling?

  • What happens if my doctor leaves the network?

This is not about whether Medicare Advantage is good or bad. It is about understanding how the plan works before you enroll.

Medicare Advantage and Referrals

Some Medicare Advantage plans may require referrals before you see certain specialists.

Medicare.gov explains that with Original Medicare, in most cases you do not need a referral to see a specialist. With Medicare Advantage, you may need a referral depending on the plan.

This can matter if you regularly see specialists or expect to need specialty care.

A good question to ask is:

Do I need a referral before seeing a specialist?

Medicare Advantage and Prior Authorization

Some Medicare Advantage plans may require prior authorization before covering certain services or supplies.

Prior authorization means the plan must approve the service before it is covered. Medicare.gov explains that Medicare Advantage plans may require approval before they cover certain services or supplies, while Original Medicare usually does not require prior approval in most cases.

A good question to ask is:

Which services require prior authorization under this plan?

This is one of the most important rules to understand before choosing a Medicare Advantage plan.

Medicare Advantage and Out-of-Pocket Costs

Medicare Advantage costs can vary by plan.

Depending on the plan, you may have costs such as:

  • Monthly premiums

  • Deductibles

  • Copayments

  • Coinsurance

  • Prescription drug costs

  • Different costs for in-network and out-of-network care

Medicare.gov explains that out-of-pocket costs vary in Medicare Advantage and that plans may have different costs for certain services. Medicare Advantage plans also have a yearly limit on what you pay for covered Medicare services. Once you reach the plan’s limit, you pay nothing for covered services for the rest of the year.

A simple way to remember it:

Medicare Advantage plans can have different costs, but they also include an annual out-of-pocket limit for covered Medicare services.

That limit can vary by plan.

Medicare Advantage and Medigap

Medicare Advantage and Medigap are not the same.

Medigap, also called Medicare Supplement Insurance, works with Original Medicare. It helps pay some out-of-pocket costs that Original Medicare does not fully cover.

Medicare Advantage is a different way to receive your Medicare benefits through a Medicare-approved private plan.

Medicare.gov explains that you cannot buy Medigap to cover your Medicare Advantage out-of-pocket costs.

A simple way to remember it:

Medigap works with Original Medicare.

Medicare Advantage is an alternative to Original Medicare.

In most cases, people are choosing between the Original Medicare path and the Medicare Advantage path. They are not using Medigap and Medicare Advantage together.

Types of Medicare Advantage Plans

There are several types of Medicare Advantage plans.

Common types include:

  • HMO plans

  • PPO plans

  • PFFS plans

  • SNP plans

  • MSA plans

Medicare.gov lists several Medicare Advantage plan types, including Health Maintenance Organizations, Preferred Provider Organizations, Special Needs Plans, Medicare Medical Savings Accounts, and Private Fee-for-Service plans.

The type of plan can affect how you use doctors, hospitals, referrals, networks, and prescription drug coverage.

For example, Medicare.gov explains that HMO plans generally require you to use doctors, providers, and hospitals in the plan’s network except for emergency care, out-of-area urgent care, and temporary out-of-area dialysis. PPO plans generally let you use out-of-network providers for covered services, but usually at a higher cost.

This page will not compare specific plan types in detail, but it is helpful to know that “Medicare Advantage” is a broad category.

When Can You Join a Medicare Advantage Plan?

You can only join, switch, or drop a Medicare Advantage plan during certain enrollment periods.

Medicare.gov explains that Medicare Advantage and Medicare drug plan changes are generally limited to specific enrollment periods, including the Initial Enrollment Period, Open Enrollment Period from October 15 to December 7, Medicare Advantage Open Enrollment from January 1 to March 31 for people already in a Medicare Advantage plan, and certain Special Enrollment Periods.

Common enrollment periods include:

  • Initial Enrollment Period

  • Annual Open Enrollment Period

  • Medicare Advantage Open Enrollment Period

  • Special Enrollment Periods

The timing depends on your situation, so it is important to understand which enrollment period applies before making changes.

Medicare Advantage Service Areas

Medicare Advantage plans are based on service areas.

You generally must live in the plan’s service area to join. Medicare.gov explains that to join a Medicare health or drug plan, you generally must live in the service area of the plan you want to join.

That means plan availability can depend on where you live.

A Medicare Advantage plan available in one county may not be available in another county. This is why Medicare Advantage research is often based on your ZIP code or county.

What Should You Check Before Choosing Medicare Advantage?

Before choosing a Medicare Advantage plan, it is helpful to ask practical questions.

Medicare.gov recommends checking whether a plan covers your prescriptions, whether your doctors and pharmacies are in the plan’s network, and reviewing costs such as monthly premiums, deductibles, and estimated yearly drug costs before joining a plan.

Questions to ask include:

  • Do I have both Part A and Part B?

  • Is this plan available where I live?

  • Are my doctors in the network?

  • Are my preferred hospitals in the network?

  • Are my prescriptions covered?

  • Are my pharmacies in the network?

  • What are the premiums, deductibles, copayments, and coinsurance?

  • Is prior authorization required for certain services?

  • Do I need referrals for specialists?

  • What happens if I travel or live in another state part of the year?

  • What is the annual out-of-pocket limit?

These questions help you understand how the plan may work in real life.

Common Misunderstandings About Medicare Advantage

“Medicare Advantage is not Medicare.”

Medicare Advantage is part of Medicare. It is also called Medicare Part C. It is another way to receive your Medicare benefits through a Medicare-approved private insurance company.

“Medicare Advantage replaces Part B.”

No. You must have both Part A and Part B to join a Medicare Advantage plan. In most cases, you also continue paying your Part B premium.

“All Medicare Advantage plans are the same.”

No. Plans can differ by service area, provider network, costs, referral rules, prior authorization rules, and prescription drug coverage.

“I can use Medigap with Medicare Advantage.”

No. Medigap works with Original Medicare. You cannot buy Medigap to cover your Medicare Advantage out-of-pocket costs.

“I can switch whenever I want.”

Usually no. You can only join, switch, or drop a Medicare Advantage plan during certain enrollment periods unless you qualify for a Special Enrollment Period.

Common Questions About Medicare Advantage

Is Medicare Advantage the same as Medicare Part C?

Yes. Medicare Advantage is also called Medicare Part C.

Do I still have Medicare if I choose Medicare Advantage?

Yes. You are still in Medicare, but you receive your Medicare-covered services through a Medicare-approved private plan.

Do I need Part A and Part B to join Medicare Advantage?

Yes. You must have both Medicare Part A and Medicare Part B to join a Medicare Advantage plan.

Does Medicare Advantage include prescription drug coverage?

Many Medicare Advantage plans include prescription drug coverage, also called Part D. Medicare.gov explains that most Medicare Advantage plans include drug coverage.

Can I have Medicare Advantage and Medigap?

No. Medigap works with Original Medicare, not Medicare Advantage. You cannot buy Medigap to cover Medicare Advantage out-of-pocket costs.

Can I see any doctor with Medicare Advantage?

Not always. With Medicare Advantage, you may need to use doctors and providers in the plan’s network and service area for non-emergency care. Some plans may cover out-of-network services, but usually at a higher cost.

Does Medicare Advantage have an out-of-pocket limit?

Yes. Medicare Advantage plans have a yearly limit on what you pay for covered Medicare services. Once you reach the plan’s limit, you pay nothing for covered services for the rest of the year.

Need Help Understanding Medicare Advantage?

Medicare Advantage can be confusing because plan rules, networks, costs, and prescription drug coverage can vary.

If you are trying to understand how Medicare Advantage compares with Original Medicare, Medigap, or Part D prescription drug coverage, we can help connect you with a licensed Medicare professional who can answer questions based on your situation.

Get Medicare help when you’re ready.