A Q and A on Medicare Advantage Plans

Medicare-approved plans from private companies, also called Part C, that replace Original Medicare as the way you get your Part A and Part B benefits.

Key takeaways

• Also called: Part C
• Must cover: everything Original Medicare covers, except hospice, which Original Medicare still pays for
• Most useful single change: Check that your doctors, hospitals and pharmacies are in the plan's network.
• Commonest mistake: Choosing a plan only for extra benefits such as gym memberships.
• See a doctor if any of the signs under "When to speak to a doctor" below apply to you.

What is Medicare Advantage Plans?

Medicare-approved plans from private companies, also called Part C, that replace Original Medicare as the way you get your Part A and Part B benefits.

Why does it matter?

They can cost less up front and add extra benefits, but networks and prior authorization rules can limit where and how you get care.

Also called for Medicare Advantage Plans?

Part C.

Must cover for Medicare Advantage Plans?

Everything Original Medicare covers, except hospice, which Original Medicare still pays for.

Drug coverage for Medicare Advantage Plans?

Most plans include Part D prescription coverage.

Out-of-pocket limit for Medicare Advantage Plans?

Every plan has a yearly limit on what you pay for covered Part A and B services.

What is the single most useful thing to do?

Check that your doctors, hospitals and pharmacies are in the plan's network.

What is the most common mistake?

Choosing a plan only for extra benefits such as gym memberships.

When should I see a doctor?

In an emergency, call 911 or go to the nearest emergency room; Medicare Advantage plans must cover emergency care in or out of network. If a plan denies care your doctor says you need, ask about a fast appeal.

More questions, answered

Can a Medicare Advantage plan drop my doctor in the middle of the year?

Yes, providers can leave a plan's network during the year. Plans are generally required to notify affected members, and in some situations, such as a significant change to the network, you may qualify for a special enrollment period to change plans. If you are in the middle of treatment, ask the plan about continuing care with that provider.

What happens in an emergency when I am away from home?

Medicare Advantage plans must cover emergency and urgently needed care anywhere in the US, whether or not the provider is in network. Call 911 or go to the nearest emergency room. Once you are stable, the plan may ask that follow-up care happen in network, so contact the plan as soon as you reasonably can.

Are the extra benefits worth choosing a plan for?

Extra benefits such as dental cleanings, eyeglasses or fitness programs can be useful, but they are usually modest and can change each year. The core medical coverage, network and drug costs have far more effect on what you pay if you get sick. Treat extras as a tiebreaker between plans that already fit your medical needs.

How does prior authorization work?

Prior authorization means the plan must approve a service before you get it for the plan to pay. Your doctor usually submits the request with supporting information. Standard requests take longer; if waiting could seriously harm your health, your doctor can ask for a fast decision. If the plan says no, you can appeal.

Can I change Medicare Advantage plans if I am unhappy?

You can change during Open Enrollment each fall, and if you are already in a Medicare Advantage plan you get one further chance to switch plans or return to Original Medicare between January 1 and March 31. Certain life events, such as moving, also open special enrollment periods.

Do I still pay the Part B premium in a Medicare Advantage plan?

Yes. You keep paying your Part B premium, and the plan may charge its own premium on top. Some plans charge no extra premium, and a few use part of their payment to reduce your Part B premium. Look at the full yearly cost, including copays, rather than the premium alone.

Related topics

• Out-of-Pocket Maximum: Sorting the Evidence From the Noise (Health Insurance and Costs)
• The Evidence on Getting a Referral and Prior Authorization, Without the Hype (Using Health Services)
• The Evidence on Travel Insurance and Healthcare Abroad, Without the Hype (Travel Health)
• Sexual Health Services: What Published Guidance Supports (Sexual Health)

Where to go next

• Medicare Advantage Plans: A Practical Checklist
• Medicare Advantage Plans: Separating Myth From Guidance
• Medicare Advantage Plans — the reference entry
• Medicare and Medicaid: The Complete Guide
• What the Guidance Really Says About Part D and Extra Help
• Medicare Enrollment Periods: What the Evidence Actually Says

When to speak to a doctor

In an emergency, call 911 or go to the nearest emergency room; Medicare Advantage plans must cover emergency care in or out of network. If a plan denies care your doctor says you need, ask about a fast appeal.

Where this comes from

• Medicare.gov — Understanding Medicare Advantage Plans
• Medicare.gov — Compare Original Medicare and Medicare Advantage

How this page was put together

Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.

Medical disclaimer

This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.