What Is Medicare Advantage?
Understand how Medicare Advantage replaces Original Medicare administration while retaining Medicare rights.
A private plan within Medicare
Medicare pays a contracted private insurer to deliver covered Part A and Part B services through an approved Advantage plan. This changes how claims are administered; it does not end your Medicare entitlement. Most such plans also provide Part D drug coverage. You must keep Part A and Part B, remain in the service area and follow the plan’s coverage rules.
Official source: Medicare: Medicare Advantage guide ↗ · Medicare: Joining a plan ↗
Benefits and plan conditions
Plans must provide medically necessary A/B services covered under Medicare, while they can set different cost sharing and network or prior-authorization rules. Some offer supplemental dental, vision or hearing benefits, but those benefits can have networks, limits or exclusions. Read the exact Evidence of Coverage instead of assuming an advertised category pays every related bill.
Official source: Medicare: Medicare Advantage guide ↗ · Medicare: Evidence of Coverage ↗
The annual medical maximum
Unlike Original Medicare without supplemental protection, an Advantage plan sets an annual limit on covered Part A and B out-of-pocket costs. A plan can have different in-network and combined out-of-network limits. The limit does not make every prescription, premium or uncovered service free. Compare an ordinary year and a high-use year using the plan’s actual medical limit and payment terms.
Official source: Medicare: Medicare Advantage guide ↗ · Medicare: Original versus Advantage ↗
The provider relationship
HMO plans ordinarily use in-network providers for nonemergency care; PPO plans commonly allow covered out-of-network visits at higher cost when the provider accepts. Even when a physician works with the parent insurer, the particular Advantage contract may differ. Verify the current directory and ask the office whether it accepts that contract for the planned service.
Official source: Medicare: HMO plans ↗ · Medicare: PPO plans ↗ · Medicare: Provider network fact sheet ↗
Joining or leaving follows a calendar
Medicare lists the fall Open Enrollment window from October 15 through December 7 and a separate January 1 through March 31 change window for current Advantage members. Initial and life-event Special Enrollment Periods also exist. Before leaving, check drug coverage, employer benefits and whether any future Medigap purchase right would exist.
Official source: Medicare: Joining a plan ↗ · Medicare: Advantage enrollment windows ↗ · Medicare: Buying Medigap ↗