Medicare Advantage


Medicare Advantage plans are part of Part C of Medicare. They were designed to be an alternative to Original Medicare and Medigap. Medicare Advantage typically has a lower premium and is available if you miss your open enrollment period for Medigap and can no longer qualify.

Medicare Advantage plans are NOT similar to Medigap plans – they are different. Members get their benefits from a private insurance company instead of original Medicare. Sometimes you’ll hear them referred to as Medicare replacement plans.

How Medicare Advantage Works

Medicare Advantage is similar to Original Medicare but is offered through private insurance companies. To enroll in Medicare Advantage (Part C), you must continue to stay enrolled in both Medicare Part A and B.

If you want to change your plan or go back to Original Medicare, you can during a future annual election period.

Medicare Advantage plans usually have low monthly premiums and cover the benefits of both Parts A and B. Many plans also come with Part D prescription drug coverage. Some plans also come with provider networks. In that case, you pay copays for medical services until you reach the plan’s out-of-pocket maximum. The OOP maximum tends to be $6700 and doesn’t include part D coverage. Furthermore, you might pay $5–$10 to see a primary care doctor, and more to see a specialist. You will likely face higher copays for diagnostic imaging, hospital stay, and surgeries. In any case, it’s a good idea to review your plan’s coverage summary to learn more about the details.

Medicare Advantage is also useful for its benefits like routine dental, vision or hearing. These services aren’t typically offered through Original Medicare. Some plans even include gym memberships. To learn more, see our page on Medicare Part C.

Medicare vs Medicare Advantage

Here’s why some people choose to get Medicare Advantage plans:

  • Many plans have low monthly premiums
  • You pay for medical services through copays and coinsurance
  • Medicare Advantage plans have an out-of-pocket maximum cap to protect you– Original Medicare plans do not
  • Some plans include both medical and Part D drug benefits
  • Some plans include benefits for things like limited vision coverage. Limitations, copayments, and restrictions may apply.

There is no single best option. Evaluate your own medical history to determine which plan is best for you.

Medigap vs Medicare Advantage

  • With Original Medicare and Medigap, you can see any doctor who accepts Medicare 9over 800,000 providers on a nationwide network)
  • Medigap plans also have fuller coverage. Medicare pays 80% and your Medigap plan 20%, so there is little out-of-pocket– Part C plans have copays
  • Medigap plans also don’t change their benefits from year to year. This means you won’t have to annually review the upcoming benefit changes like on a Medicare Advantage plan.
  • Medigap plans do not include Part D coverage, so you need to buy a separate Part D policy for prescription drug coverage
  • Medicare Advantage plans may offer routine dental, vision or hearing while Medigap plans do not

Provider Networks

HMO: HMO plans are the most comment type of MA plan. They generally require that you only visit network providers, except in the case of emergencies. You will need to select a primary care physician, who can write you a referral if you need to see a specialist. HMO plans, unlike PPO plans, can limit your out-of-network coverage.

PPO: PPO plans allow you to see any provider that accepts Medicare. Furthermore, there is no referral necessary to see out-of-network providers. However, if you do go to an out-of-network provider, you will have to pay more out of pocket.

PFFS: In some areas, there are Medicare Private-Fee-for-Service plans. These plans may have a network and may include Part D. If the plan does have a network, you can pay extra to visit a non-network provider. In this case, you must check beforehand if the provider accepts your plan, unless it is an emergency. Furthermore, they will not be able to charge you cost-sharing greater than what you would normally pay in your PFFS plan.

Basic Rules

  • You must be enrolled in both Medicare Part A & B and live in the plan service area. If you have Medicare Advantage and decide to drop part B, you will lose your Medicare Advantage coverage!
  • Medicare Advantage plans cannot ask you health-related questions unless they affect your eligibility. This basically means they will only ask if you have been diagnosed with End-Stage Renal Disease.
  • You’ll pay the lowest out of pocket if you only see network providers:
    • HMO and PPO plans pay have networks.
    • Most HMO plans don’t cover non-network providers except in emergencies.
    • In PPO networks, seeing a provider outside the network will be much more expensive.
  • Get prior authorization for certain procedures, especially in Medicare Advantage HMO plans.
  • On many HMO plans, you must obtain a referral from your primary care physician to see a specialist
  • You must direct your providers to bill your Medicare Advantage plan.
  • People who enroll in Advantage plans for Medicare are agreeing, for the rest of the calendar year, to be covered by the plan.

Medicare Advantage Enrollment Periods

You may enroll in a Medicare Advantage plan during the Initial Enrollment Period when you first turn 65. After that, you may enroll or dis-enroll only during the Annual Election Period. Once you enroll in Medicare Advantage, you must stay enrolled in the plan for the rest of the calendar year.

The Annual Election Period (October 15th – December 7th). Any changes made to your plan then will take effect on January 1.

If you decide to leave a Medicare Advantage plan and return back to Original Medicare, you must notify your Medicare Advantage plan carrier.

Medicare Advantage Disenrollment Period

If you are unaware of all the rules about enrollment, you may try to get Medicare without an agent. However, you might find yourself enrolled in a plan that your doctor doesn’t accept or that doesn’t cover the medication you need. In case this happens, there is a Medicare Advantage Disenrollment Period. This period is to allow yout o disenroll form a Medicare Advantage plana nd return to Original Medicare. The MADP lasts from January 1st – February 14th each year.

Keep in mind, this does not guarantee that you can return to a Medigap plan you may have had before. If this was your first time in a Medicare Advantage plan, you have 12 month “trial period”. This means that within 12 months of first enrolling, you can disenroll and rejoin a Medigap plan without going through medical underwriting or answering health questions.

Factors to Keep in Mind About Medicare Advantage

Be sure to carefully consider these things before joining a plan:

  • Advantage plans usually have provider networks. Ask an agent to help you find a plan that is accepted by your medical providers.
  • Benefits may change every year. The plan’s benefits, formulary, pharmacy network, provider network, premium and/or co-payments and co-insurance may change on January 1 of each year. You will find out what is changing every September.
  • Your enrollment is generally for the entire year–you can only disenroll at a specific time. If you don’t like your plan, you have to wait until the following annual election period begins in October, the MADP in January, or use a special election period (if you qualify).
  • If you enroll as soon as you’re eligible, you need to be sure you want this coverage. Your open enrollment window to get a Medigap plan with no health questions ends at 6 months past your Part B effective date. After that, you will have to answer health questions if you want to join a plan. You may be denied if you are not healthy enough.


Which Medicare Advantage plan is the best varies on an individual basis. There is no one plan that we can recommend without first evaluating your personal details. Finding a Medicare plan is an important decision and it’s worth consulting an agent so you don’t make a critical mistake. Feel free to call now at 212-484-9888 so we can start going over some options today.