Original Medicare leaves gaps. No out-of-pocket maximum. No dental coverage. No vision benefits. No prescription drug coverage unless you buy a separate Part D plan. Medicare Advantage fills those gaps by bundling everything into one private insurance plan. More than half of all Medicare beneficiaries now choose Medicare Advantage over Original Medicare. This guide walks through how these plans work, what they cover, what they cost, and who should choose them.
What is Medicare Advantage?
Medicare Advantage is the private insurance alternative to Original Medicare. The government calls it Medicare Part C. Private insurance companies approved by Medicare run these plans.
Here is what you need to know. When you choose a Medicare Advantage plan, the private insurance company takes over the administration of your Medicare benefits. The government still pays for it, but the insurance company handles your claims, builds your provider network, and manages your care.
The Balanced Budget Act of 1997 created this program. Back then it was called Medicare+Choice. In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act renamed it to Medicare Advantage.
One thing to understand. You are still in the Medicare program. You still have Medicare rights and protections. You just get your benefits through a private plan instead of directly from the government.
How Medicare Advantage Plans Work
Private Insurers Run These Plans
Medicare pays private insurance companies a set amount each month to cover your benefits. The insurance company then manages your coverage. Companies like Humana, UPMC, Sanford Health Plan, and many others offer these plans.
These private insurers must follow Medicare rules. But they have flexibility in how they structure their plans, what extra benefits they offer, and what you pay out of pocket.
Network-Based Care
Most Medicare Advantage plans require you to use doctors and hospitals inside their network. This is the biggest difference from Original Medicare.
With Original Medicare, you can see any doctor in the country that accepts Medicare. With most Medicare Advantage plans, you stay inside a network. Go outside that network, and your costs go up. In some plans, out-of-network care is not covered at all except for emergencies.
One Plan, One Card
Medicare Advantage bundles everything into one plan. You get your hospital coverage (Part A), medical coverage (Part B), and usually prescription drug coverage (Part D) all in one package. You carry one card. You make one phone call for customer service.
Many plans also include extra benefits that Original Medicare does not cover. Dental, vision, hearing, gym memberships, and wellness programs are common additions.
Types of Medicare Advantage Plans
Not all Medicare Advantage plans work the same way. The type you choose affects your costs, your choice of doctors, and how you get referrals to specialists.
Health Maintenance Organization (HMO)
HMO plans, or Health Maintenance Organization plans, are the most common type of Medicare Advantage plan. They focus on coordinated care and cost control.
Here are the rules. You generally must get your care from doctors and hospitals inside the plan’s network. You usually need a referral from your primary care doctor to see a specialist. Emergency care and urgent care are covered even if they are out of network, but routine care is not covered in that situation.
The trade-off is lower costs. HMO plans often have lower monthly premiums and lower out-of-pocket costs than other plan types. Many HMO plans offer $0 monthly premiums.
Preferred Provider Organization (PPO)
PPO plans give you more flexibility at a higher cost.
You can see doctors inside or outside the network. Your costs are lower when you stay in the network, but you have the option to go out if you are willing to pay more.
You do not need referrals to see specialists. You can make an appointment with any specialist directly. This is a big advantage for people who want more control over their care.
PPO plans typically have higher monthly premiums than HMO plans. But the trade-off is the freedom to choose your providers.
Private Fee-for-Service (PFFS)
PFFS plans work differently from HMO and PPO plans.
The plan decides how much it will pay for each service and what you will pay. You can see any Medicare-approved doctor or hospital that accepts the plan’s payment terms.
Here is the catch. Not every provider will accept a PFFS plan. You need to confirm before each appointment that the provider agrees to treat you under the plan’s terms. If they do not accept the terms, you pay the full bill.
Some PFFS plans have networks. Some do not. If the plan has a network, you can still go out of network, but you may pay more.
Special Needs Plan (SNP)
SNPs are designed for specific groups of people with special health needs.
There are three types of SNPs:
- Chronic condition SNPs for people with certain chronic illnesses like diabetes, heart disease, or lung disease
- Institutional SNPs for people who live in nursing homes or need facility-level care
- Dual-eligible SNPs for people who qualify for both Medicare and Medicaid
All SNPs must include prescription drug coverage. They focus on coordinated care from providers who specialize in the member’s specific condition.
Medical Savings Account (MSA) Plan
MSA plans are the least common type of Medicare Advantage plan.
They combine two parts. A high-deductible health plan covers your medical services. A special savings account receives deposits from Medicare that you can use to pay your medical bills before you meet the deductible.
MSA plans do not include prescription drug coverage. You would need a separate Part D plan. You also do not pay a separate monthly premium for the MSA plan, though you still pay your Part B premium.
Medicare Advantage Coverage
Hospital Coverage (Part A)
Medicare Advantage plans cover everything Original Medicare Part A covers. That means inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services.
The difference is in how you access these services. With Original Medicare, you can go to any hospital that accepts Medicare. With a Medicare Advantage plan, you generally need to use hospitals inside your plan’s network.
Medical Coverage (Part B)
Part B coverage includes doctor visits, outpatient care, preventive services, durable medical equipment, physical therapy, and mental health services.
Again, the coverage is the same as Original Medicare. The difference is the network. Your plan’s network doctors and hospitals provide these services.
Dental Coverage
Original Medicare does not cover routine dental care.
Many Medicare Advantage plans include dental benefits. The coverage varies by plan. Some cover preventive care only. Others cover basic and major services like crowns and dentures. Check each plan’s dental benefits carefully before enrolling.
Vision Coverage
Original Medicare does not cover routine eye exams or glasses. It only covers eye care related to medical conditions like cataracts or glaucoma.
Medicare Advantage plans frequently include vision benefits. Routine eye exams are common. Some plans also include allowances for glasses or contact lenses.
Prescription Drug Coverage (Part D)
Most Medicare Advantage plans include prescription drug coverage. These are called MAPD plans (Medicare Advantage Prescription Drug plans).
If you join an HMO or PPO plan that does not include drug coverage, you cannot buy a separate Part D plan. You would have no prescription drug coverage through Medicare.
If you join a PFFS plan that does not include drug coverage, you can buy a separate Part D plan. SNPs must include drug coverage. MSA plans do not include drug coverage.
Each plan has a formulary. That is the list of drugs the plan covers. Check the formulary before enrolling to make sure your medications are covered.
Extra Benefits
Medicare Advantage plans can offer supplemental benefits that Original Medicare does not cover. These benefits must be primarily health-related, though plans can offer non-health-related benefits to people with chronic conditions.
Common extra benefits include:
- Fitness programs like SilverSneakers
- Hearing exams and hearing aids
- Transportation to medical appointments
- Meal delivery after a hospital stay
- Over-the-counter allowances for health products like bandages and pain relievers
Medicare Advantage Costs
Monthly Premiums
You have two premiums to think about with Medicare Advantage.
First, you still pay your Part B premium to Medicare. In 2026, the standard Part B premium is $202.90 per month. Higher income earners pay more.
Second, you may pay an additional premium to your Medicare Advantage plan. Many plans offer $0 monthly premiums. Others charge between $0 and $50 per month. Some premium plans cost more, especially PPO plans that offer more flexibility.
MSA plans are different. You do not pay a separate monthly premium for an MSA plan, though you still pay your Part B premium.
Deductibles
Original Medicare has separate deductibles for Part A and Part B. In 2026, the Part A deductible is $1,736 per benefit period. The Part B deductible is $283 per year.
Medicare Advantage plans have their own deductibles. Some plans have no deductible. Some have a medical deductible. Some have a separate drug deductible. Deductibles vary widely by plan, so you need to check each plan’s structure.
Copays and Coinsurance
Copays are fixed amounts you pay for specific services. For example, you might pay $15 to see your primary care doctor or $45 to see a specialist.
Coinsurance is a percentage of the cost. For example, you might pay 20 percent of the cost of a surgical procedure.
Original Medicare uses coinsurance. You pay 20 percent of the Medicare-approved amount for most services after you meet your deductible.
Medicare Advantage plans often use copays instead of coinsurance. Copays give you predictable costs. You know exactly what you will pay for a doctor visit or a lab test before you walk in the door.
Out-of-Pocket Maximum
This is one of the biggest advantages of Medicare Advantage over Original Medicare.
Medicare Advantage plans have an annual out-of-pocket maximum for medical services. Once you reach that limit, the plan pays 100 percent of covered services for the rest of the year.
Original Medicare has no out-of-pocket maximum. If you have a serious illness or injury, your 20 percent coinsurance could add up to thousands of dollars with no upper limit.
The out-of-pocket maximum varies by plan. Lower maximums usually come with higher premiums. Higher maximums usually come with lower premiums. Choose based on how much risk you can afford to take.
Pros of Medicare Advantage
- Lower upfront costs. Many plans have $0 monthly premiums. You only pay your Part B premium.
- Out-of-pocket maximum. Your costs stop once you hit the plan’s limit. Original Medicare has no such protection.
- Extra benefits. Dental, vision, hearing, fitness, and wellness programs are not covered by Original Medicare.
- Drug coverage included. Most plans bundle prescription drug coverage so you do not need a separate Part D plan.
- Care coordination. HMO plans especially focus on coordinating your care, which can be helpful if you have multiple chronic conditions.
- One card, one plan. Simpler administration than original Medicare plus a separate drug plan plus a separate supplement plan.
Cons of Medicare Advantage
- Network restrictions. You generally must use doctors and hospitals inside your plan’s network. Out-of-network care costs more or is not covered.
- Referral requirements. HMO plans require referrals to see specialists. This adds steps and delays to your care.
- Prior authorization. Many Medicare Advantage plans require prior approval for expensive services like surgeries, imaging, and some medications.
- Plan exits. Plans can leave your area. In 2026, roughly one in 10 Medicare Advantage enrollees had to find new coverage because their plan stopped operating in their area.
- Switching back to Original Medicare can be hard. If you want to switch back to Original Medicare and buy a Medigap supplement plan, you may face medical underwriting. Insurers can deny you or charge higher premiums based on your health conditions.
- Travel coverage. Most plans only cover emergency care when you travel outside your plan’s service area. Routine care is not covered.
Medicare Advantage vs. Medigap
This is where people get confused. Let me clear it up.
What is Medigap?
Medigap is Medicare Supplement Insurance. It works alongside Original Medicare, not instead of it. You keep Original Medicare Parts A and B. You buy a Medigap policy from a private insurer to pay some of the costs that Original Medicare does not cover.
Medigap pays things like:
- Part A deductibles and coinsurance
- Part B deductibles and coinsurance
- Skilled nursing facility coinsurance
- Foreign travel emergency care
Medigap does not include prescription drug coverage. You would need a separate Part D plan. Medigap does not include dental, vision, or hearing benefits.
The Key Differences
- How they work. Medicare Advantage replaces Original Medicare. Medigap supplements Original Medicare.
- Networks. Medicare Advantage plans have networks. Medigap lets you see any doctor that accepts Medicare anywhere in the country.
- Out-of-pocket maximum. Medicare Advantage has an out-of-pocket maximum. Medigap does not have a separate out-of-pocket maximum, but it pays most of your costs so your out-of-pocket exposure is limited.
- Premiums. Medicare Advantage often has low or $0 premiums. Medigap has higher monthly premiums but predictable costs.
- Extra benefits. Medicare Advantage includes dental, vision, hearing, and fitness. Medigap does not.
- Enrollment windows. You have a guaranteed right to buy Medigap when you first turn 65. After that six-month window closes, Medigap insurers can deny you or charge higher premiums based on your health in most states.
Which One Is Better?
There is no universal answer. It depends on your situation.
Choose Medicare Advantage if you want lower monthly premiums, extra benefits like dental and vision, and an out-of-pocket maximum. Accept that you will have network restrictions and may need referrals and prior authorizations.
Choose Original Medicare plus Medigap if you want the freedom to see any doctor anywhere, do not want to deal with referrals and prior authorizations, and can afford higher monthly premiums. Understand that you will need separate drug coverage and will not have dental or vision benefits unless you buy separate policies.
Who Should Choose Medicare Advantage
- People who want predictable costs. The out-of-pocket maximum protects you from catastrophic expenses. Copays are predictable.
- People who want extra benefits. If you need dental care, vision exams, or hearing aids, Medicare Advantage often covers these when Original Medicare does not.
- People who are healthy. If you do not see many specialists and do not travel frequently, the network restrictions may not bother you.
- People who can use a network. If your doctors and hospitals are in the plan’s network, you will have lower costs and fewer hassles.
- People who want simplicity. One plan. One card. One premium (plus Part B). No separate drug plan. No separate supplement plan.
- People with limited budgets. $0 premium plans make Medicare Advantage accessible to people who cannot afford Medigap premiums.
- Poor Candidates for Medicare Advantage
- People who travel frequently. Most plans only cover emergency care outside your service area. Routine care is not covered.
- People with complex conditions requiring multiple specialists. HMO plans require referrals for each specialist. This adds administrative burden.
- People whose doctors are not in any Medicare Advantage network. If your preferred providers do not contract with Medicare Advantage plans, you cannot see them.
- People who want the freedom to see any doctor. Original Medicare plus Medigap gives you national access. Medicare Advantage does not.
- People with end-stage renal disease (ESRD). In most cases, you cannot join a Medicare Advantage plan if you have ESRD, unless you join a special needs plan designed for ESRD.
Enrollment Process
Initial Enrollment Period (IEP)
Your first chance to join Medicare Advantage is when you first become eligible for Medicare.
The Initial Enrollment Period lasts seven months. It starts three months before you turn 65, includes the month you turn 65, and ends three months after.
During this window, you can enroll in any Medicare Advantage plan available in your area. You cannot be denied based on your health. No medical underwriting.
Annual Enrollment Period (AEP)
The Annual Enrollment Period runs from October 15 to December 7 every year.
During AEP, you can:
- Switch from Original Medicare to a Medicare Advantage plan.
- Switch from one Medicare Advantage plan to another.
- Drop your Medicare Advantage plan and return to Original Medicare.
- Join, switch, or drop a Part D prescription drug plan.
Changes made during AEP take effect on January 1.
Medicare Advantage Open Enrollment Period (OEP)
The Medicare Advantage Open Enrollment Period runs from January 1 to March 31 every year.
During OEP, you can:
- Switch from one Medicare Advantage plan to another.
- Drop your Medicare Advantage plan and return to Original Medicare.
You cannot use OEP to join a Medicare Advantage plan if you are not already in one. That is for AEP.
Special Enrollment Period (SEP)
Life events can trigger a special enrollment period that lets you change plans outside the regular windows.
Qualifying events include the following:
- Moving outside your plan’s service area
- Losing your current coverage
- Qualifying for Medicaid
- Moving into or out of a nursing home
- Your plan to leave your area or reduce its service area
When a qualifying event happens, you generally have 60 days before and 63 days after the event to make changes.
How to Enroll
You have three ways to enroll in a Medicare Advantage plan.
- Online at Medicare.gov. The Medicare Plan Finder lets you compare plans available in your area. You can enroll directly through the website.
- By phone. Call 1-800-MEDICARE (1-800-633-4227). A representative can help you compare plans and enroll over the phone.
- Through the plan directly. You can call the insurance company offering the plan. They will walk you through the enrollment process.
- With help from a broker or agent. Licensed insurance agents can help you compare plans and enroll. Their services are free to you because insurance companies pay them commissions.
Do these three things before you choose a plan.
- Check that your doctors are in-network. Call your doctors’ offices or check the plan’s online provider directory. If your doctors are not in-network, you will have to switch doctors or pay more.
- Check that your drugs are on the formulary. Each plan has a list of covered drugs. Make sure your medications are on that list. Check the copay tier for each drug.
- Check the plan’s star rating. Medicare rates plans on a scale of 1 to 5 stars based on quality and customer service. Higher-rated plans generally provide better service.
Here is something most people do not know. If you leave Medicare Advantage and switch back to Original Medicare, you may not be able to buy a Medigap supplement plan.
In most states, Medigap insurers can use medical underwriting outside your initial enrollment window. That means they can:
- Deny you coverage based on your health conditions.
- Charge you higher premiums
- Impose waiting periods for pre-existing conditions.
If you have chronic conditions like diabetes, heart disease, or cancer, you could be denied Medigap coverage entirely. Then you would be stuck with Original Medicare and no out-of-pocket maximum. Your 20 percent coinsurance would have no limit.
If your Medicare Advantage plan leaves your area, you get a guaranteed-issue right to buy Medigap without medical underwriting. But if you leave voluntarily, you may not have that protection.
Do not drop your Medicare Advantage plan until you have confirmed you can get Medigap coverage. Check with Medigap insurers first. Get approved. Then switch.
Free help is available from your State Health Insurance Assistance Program (SHIP). Visit shiphelp.org or call 877-839-2675. SHIP counselors can help you understand your options in your state.
Final Thoughts
Medicare Advantage is not better or worse than Original Medicare. It is different. You trade the freedom to see any doctor for lower upfront costs, an out-of-pocket maximum, and extra benefits like dental and vision. The right choice depends on your health, your budget, your doctors, and your tolerance for network restrictions. Use the Annual Enrollment Period from October 15 to December 7 to compare plans in your area. Check that your doctors are in network. Check that your drugs are on the formulary. And if you leave Medicare Advantage for Original Medicare, make sure you can get a Medigap plan before you switch.
