Medicare Part C Explained
What Is Medicare Advantage?
Understand how Medicare Advantage works, including provider networks, prescription coverage, cost sharing and the annual maximum out-of-pocket limit.
How Medicare Advantage Works
You must remain enrolled in Medicare Parts A and B and continue paying any applicable Part B premium. The Medicare Advantage plan then administers your covered Medicare services according to the plan’s benefits, provider rules and cost sharing.Most Medicare Advantage plans include Part D prescription drug coverage. Many plans may also offer benefits that Original Medicare generally does not cover, such as certain dental, vision, hearing, fitness or over-the-counter benefits.
Medicare Advantage is not a Medicare Supplement.
Medicare Advantage replaces Original Medicare as the primary way your Medicare benefits are administered. A Medicare Supplement instead works alongside Original Medicare and helps pay certain costs Medicare leaves behind.
How coverage is organized
What Does a Medicare Advantage Plan Include?
A Medicare Advantage plan must provide:
- Medicare Part A hospital benefits
- Medicare Part B medical benefits
- Emergency and urgently needed care according to Medicare requirements
Depending on the particular plan, it may also include:
- Part D prescription drug coverage
- Routine dental services
- Routine vision services
- Routine hearing services
- Fitness or wellness benefits
- Transportation under specified circumstances
- Over-the-counter allowances
- Other supplemental benefits for eligible members
Additional benefits are plan-specific.
Benefit availability, allowances, provider access, limitations and eligibility rules vary by plan, service area and coverage year. Do not assume every plan includes the same extras or that every advertised benefit will apply to your circumstances.
Network structure
Common Types of Medicare Advantage Plans
HMO
Health Maintenance Organization
An HMO generally expects routine non-emergency care to be received from participating network providers, except under certain protected circumstances.
Some HMO plans require referrals or prior authorization for particular specialists, procedures or services.
PPO
Preferred Provider Organization
A PPO may allow covered care from out-of-network providers, but the beneficiary will generally pay more.
An out-of-network provider may also decline to treat the member except when other requirements apply.
HMO-POS
HMO With Point-of-Service Benefits
An HMO-POS generally follows HMO network rules but may permit specified services outside the network under the plan’s point-of-service benefits.
Other plan types
PFFS, MSA and Special Needs Plans
Other Medicare Advantage structures may follow different rules. Special Needs Plans are designed for beneficiaries who meet specific eligibility requirements.
Review the plan’s official materials rather than assuming every Medicare Advantage plan functions like an HMO or PPO.
Provider access
Doctors, Hospitals and Plan Networks
Provider access is one of the most important considerations when comparing Medicare Advantage plans.
Depending on the plan type, you may need to use participating doctors, hospitals, laboratories, rehabilitation providers and medical equipment suppliers for routine non-emergency care.
Providers to check before enrolling
- Primary care physician
- Every specialist you regularly see
- Preferred hospitals and outpatient facilities
- Urgent care locations
- Physical therapy and rehabilitation providers
- Home healthcare agencies
- Laboratory and diagnostic imaging locations
- Durable medical equipment suppliers
- Mental and behavioral healthcare providers
Check the exact provider, location and plan.
A healthcare system appearing in a directory does not necessarily prove that every affiliated doctor, practice or location participates. Likewise, one insurance company may offer several plans that use different networks.
Understanding plan costs
Medicare Advantage Is Not Cost-Free
Some Medicare Advantage plans have a low or $0 additional plan premium, but this does not mean healthcare is free.
You must continue paying any applicable Medicare Part B premium. Depending on the plan and services used, you may also pay:
- An additional plan premium
- Medical or prescription deductibles
- Primary care and specialist copays
- Hospital copays or coinsurance
- Outpatient procedure costs
- Ambulance copays
- Diagnostic imaging costs
- Durable medical equipment coinsurance
- Prescription copays or coinsurance
- Higher costs for permitted out-of-network care
Compare the cost of using the plan—not only its premium.
A plan with a low premium can still create substantial expenses during a year involving hospitalization, surgery, rehabilitation, diagnostic testing or specialist care.
Financial protection
Maximum Out-of-Pocket Protection
Medicare Advantage plans include an annual maximum out-of-pocket limit for covered Medicare Part A and Part B services.
Once you reach the applicable limit, the plan pays for covered Part A and Part B services for the remainder of that calendar year according to its rules.
The medical MOOP does not include every expense.
Medicare Part B premiums, plan premiums, non-covered services and Part D prescription expenses generally do not count toward the Medicare Advantage medical maximum out-of-pocket limit.
PPO plans may have one maximum for in-network services and a higher combined maximum involving in-network and covered out-of-network services. Review both numbers when comparing plans.
Part D coverage
Prescription Drug Coverage
Most Medicare Advantage plans include Part D prescription drug coverage. These plans are often called MAPD plans.
Before enrolling, compare:
- Every prescription and dosage
- The plan’s formulary
- Medication tiers
- Drug deductibles
- Copays and coinsurance
- Preferred and standard pharmacies
- Mail-order availability
- Prior authorization
- Step therapy
- Quantity limits
Medical and prescription costs use separate protections.
Part D prescription spending does not generally count toward the Medicare Advantage medical MOOP. Part D has its own cost-sharing structure and annual out-of-pocket protection.
In most HMO and PPO Medicare Advantage plans that do not include drug coverage, you cannot simply add a separate standalone Part D plan. Exceptions can apply to certain other plan types and circumstances.
Plan rules
Referrals and Prior Authorization
A provider being in-network does not automatically mean every service will be covered without additional steps.
A Medicare Advantage plan may require:
- A referral from a primary care provider
- Prior authorization before a procedure or service
- Use of a particular facility
- Documentation showing medical necessity
- Step therapy for certain medications
- Use of participating medical equipment suppliers
In-network does not always mean pre-approved.
Ask who is responsible for requesting authorization and confirm approval before receiving scheduled non-emergency care.
Care away from home
Emergency, Urgent and Travel Coverage
Medicare Advantage plans must cover emergency and urgently needed care according to Medicare requirements, including when you are outside the plan’s local service area.
Follow-up and routine care after an emergency may still be subject to network and authorization requirements.
Coverage for routine non-emergency care while traveling depends on the particular plan and plan type. People who travel frequently or live in another state for part of the year should review these rules carefully.
Emergency coverage is not routine out-of-network coverage.
Do not use emergency protections as a substitute for understanding the plan’s rules for scheduled or ongoing care away from home.
Compare the complete picture
What Should You Compare Between Plans?
| Consideration | Questions to Ask |
|---|---|
| Providers | Are my doctors, hospitals and facilities in-network at the locations I use? |
| Prescriptions | Are my drugs covered, and what restrictions or costs apply? |
| Premium | Is there an additional plan premium beyond my Part B premium? |
| Medical costs | What will I pay for specialists, hospitals, surgery, imaging and equipment? |
| MOOP | What are the in-network and combined maximum out-of-pocket limits? |
| Network type | Is the plan an HMO, PPO, HMO-POS or another structure? |
| Authorization | Which services require referrals or prior authorization? |
| Travel | How does the plan handle routine care away from the service area? |
| Additional benefits | What is actually covered, and which limits or providers apply? |
Personal priorities
When Might Medicare Advantage Be Worth Exploring?
Medicare Advantage may be worth comparing when:
- Your important doctors and hospitals participate in the plan
- Your prescriptions are handled affordably
- You are comfortable using the plan’s network and service area
- You prefer bundled medical and prescription coverage
- The plan’s cost sharing fits your expected healthcare usage
- You value additional benefits offered by the particular plan
- You understand the maximum financial exposure
Medicare Advantage may be less attractive when your providers do not participate, you need broad routine access outside the service area, or the plan’s authorization and cost-sharing rules do not fit your needs.
There is no universally best Medicare Advantage plan.
The appropriate comparison depends on your location, eligibility, doctors, prescriptions, healthcare needs, travel habits and budget.
Continue your research
Medicare Advantage Resources
Coverage comparison
Advantage vs. Supplement
Compare provider access, premiums, healthcare costs, prescriptions and travel considerations.
Compare the two approaches →Plan selection
How to Compare Advantage Plans
Learn why doctors, medications, hospitals and total costs matter more than selecting a plan from advertisements alone.
Learn how to compare plans →Enrollment
Turning 65 Medicare Guide
Understand when Medicare enrollment may be automatic, how employer coverage affects timing and what to prepare.
Read the Turning 65 guide →Frequently asked questions
Medicare Advantage Questions
Does Medicare Advantage replace Medicare?
It does not eliminate Medicare eligibility. You remain enrolled in Parts A and B, but the private Medicare Advantage plan administers your covered Medicare benefits.
Do I still pay the Part B premium?
Yes. You must continue paying any applicable Medicare Part B premium while enrolled in Medicare Advantage. You may also owe an additional plan premium.
Are Medicare Advantage plans free?
No. Some plans have a $0 additional plan premium, but beneficiaries may still pay the Part B premium, deductibles, copays, coinsurance, prescription costs and other applicable expenses.
Can I keep all of my doctors?
Only if the doctors and locations participate under the exact plan or the plan permits covered out-of-network care. Verify each provider before enrolling.
Do all Medicare Advantage plans include Part D?
Most include Part D, but not all do. Whether separate Part D coverage can be added depends on the Medicare Advantage plan type.
Does the medical MOOP include prescriptions?
Generally, no. Medicare Advantage medical cost sharing and Part D prescription spending use separate out-of-pocket protections.
Can Medicare Advantage require prior authorization?
Yes. Plans may require prior authorization for certain services, procedures, equipment or medications.
Can I change Medicare Advantage plans later?
Changes are generally permitted only during an applicable enrollment period or Special Enrollment Period. The options available depend on your circumstances and timing.
Explore Medicare Advantage and Part D Options
Plan availability depends on location, eligibility and coverage year. Online tools are provided for educational comparison and do not replace a personalized review of doctors, prescriptions and healthcare needs.
Compare Medicare Advantage Plans With Benjamin
Benjamin Thompson can help you compare available coverage using your doctors, hospitals, prescriptions, healthcare needs and budget—without high-pressure sales.
This page provides general educational information. Plan availability, premiums, benefits, provider participation, formularies, cost sharing and coverage rules vary by plan, location, eligibility and coverage year. Review current official plan materials before enrolling.