[Last updated August 25, 2025]
Medicare Advantage, also known as Medicare Part C, is an alternative way to receive Medicare benefits. This guide can help seniors, adult children, and caregivers make informed decisions by explaining what Medicare Advantage is, how it works, what it covers, and how it differs from the federal government’s original Medicare program.
What is Medicare Advantage?
According to the Medicare website: “Medicare Advantage (also known as ‘Part C’) is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health coverage. These ‘bundled’ plans include Part A, Part B, and usually Part D.”
In plain English, Medicare Advantage replaces the federal government’s original Medicare hospital and medical insurance coverage with a plan run by a private insurance company. Many Medicare Advantage plans also include prescription drug coverage, so most of your needs are available in one place.
Below is a table comparing original Medicare to Medicare Advantage.
| Feature | Original Medicare (Parts A and B) | Medicare Advantage (Part C) |
|---|---|---|
| Hospital coverage | Yes (Part A) | Yes (through the plan) |
| Doctor visits and outpatient care | Yes (Part B) | Yes (through the plan) |
| Prescription drugs | Not included (need to buy Part D) | Almost always included |
| Extra benefits | Very limited | Often dental, vision, hearing, and wellness programs |
| Provider flexibility | Can see any Medicare provider | Usually limited to the plan’s network (like HMO/PPO) |
How Medicare Advantage works
- Medicare pays private insurance companies to provide your coverage.
- You still pay your Part B premium, and sometimes an additional plan premium.
- The plan manages your care, often with a network of providers and coverage rules.
- Annual plan review is essential, as costs, networks, and benefits can change each year.
What Medicare Advantage covers
A major difference between the two Medicare alternatives is what they cover. Let’s look at what services each one includes.
Services covered by both original Medicare and Medicare Advantage:
- Hospital stays, short-term skilled nursing, and hospice care (Part A).
- Doctor visits and outpatient care (Part B).
- Lab tests, X-rays, and some preventive services.
- Durable medical equipment.
Additional services Medicare Advantage may cover, but original Medicare doesn’t:
- Prescription drugs.
- Dental, vision, and hearing care.
- Fitness programs or gym memberships.
- Over-the-counter allowances, transportation, or wellness services.
Note: Coverage varies from insurer to insurer and even among one insurer’s plans, so you should always check a plan’s details carefully.
How Medicare Advantage differs from original Medicare
Medicare Advantage differs from original Medicare in many ways beyond just what it covers.
| Feature | Original Medicare | Medicare Advantage |
|---|---|---|
| Coverage structure | Fee-for-service, where the government-run program pays doctors and hospitals directly for each covered service. | The government pays a private insurance company to provide your coverage. The insurer designs and administers your plan under Medicare rules and pays its contracted service providers. |
| Provider networks | You can see any doctor or hospital in the U.S. that accepts Medicare without needing referrals. | Most plans require you to use their network of doctors and hospitals (like an HMO or PPO). Going outside the network may cost more or may not be covered at all. |
| Out-of-pocket maximum | No annual limit means you’re open to high medical costs that can keep adding up. | Your plan must set a yearly out-of-pocket maximum for Part A and Part B services. It also must incorporate a separate ceiling for Part D prescription drug out-of-pocket expenditures. Once you hit each ceiling, the plan pays 100% of covered services. |
| Extra benefits | Minimal; covers primarily preventive services, but no routine dental, vision, or hearing coverage. | Benefits vary widely by plan but often include extras like dental checkups, eyeglasses, hearing aids, fitness programs, or transportation. |
| Prescription drugs | No coverage; you need to buy a separate Part D plan if you want drug coverage. | Most Medicare Advantage plans include Part D coverage, so you don’t need a separate plan. |
Costs
While Medicare Advantage may look less expensive up front, the real costs depend on how often you need care. Here are the main cost elements:
- Premiums: Some plans have $0 monthly premiums; others charge extra. Almost everyone also pays the Medicare Part B monthly premium (projected at $206.50 for 2026, up from $185 in 2025).
- Deductibles: Some plans have an annual deductible to meet before the plan starts paying. Your prescription drug coverage may have a separate deductible to meet.
- Copayments/coinsurance: These fees are charged per visit or service, and they will vary by plan and the doctor or service.
- Out-of-pocket maximum: Plans must cap annual spending for covered Part A and Part B services. In 2025, spending can’t exceed $9,350 for in-network services (and $14,000 if it includes out-of-network services), although plan limits are often lower. Part D prescription drug spending has a separate out-of-pocket ceiling of no more than $2,000 for 2025. After this, the plan pays 100%.
- Extra benefits: Extras like gym memberships may be fully paid for, while others (like dentures or hearing aids) may have higher copayments or benefit maximums.
Tip: Compare plans carefully, because total costs depend on how often you need care.
Enrollment
You generally have four big opportunities to add or change coverage:
- Initial enrollment period (IEP): When you first become eligible for Medicare, typically the seven months around your 65th birthday. You must have Medicare Part A and Part B to access Medicare Advantage.
- Annual election period (AEP): October 15 to December 7 each year, when you can join, switch, or leave a Medicare Advantage plan.
- Medicare Advantage open enrollment period (MA OEP): January 1 to March 31 each year, when you can switch Medicare Advantage plans or return to original Medicare.
- Special enrollment periods (SEPs): Triggered by events like moving, losing other coverage, or qualifying for Medicaid. The event determines the rules and timing of the period. You can leave Medicare Advantage and return to original Medicare anytime during a SEP.
Pros and cons
Pros of Medicare Advantage:
- Bundled coverage with hospital, medical, and (often) prescription drugs all in one plan.
- Extra benefits like dental, vision, hearing, wellness, or transportation often included.
- Predictable costs with an annual out-of-pocket maximum protecting against high costs.
- Just one consolidated premium to pay (plus the Medicare Part B premium).
Cons of Medicare Advantage:
- Must use restricted provider networks to access the lowest costs.
- Prior authorization required from the insurer can delay care.
- Annual changes to plan rules and costs call for careful review each year.
- Limited flexibility to find providers if you travel out of your network’s home area.
Where to learn more
For official information and plan comparison, visit:
- Compare Original Medicare and Medicare Advantage.
- Understanding Medicare Advantage Plans.
- Explore your Medicare coverage options (comparative tool).
These resources allow you to explore plans in your area, review benefits, and compare costs.
Medicare Advantage is a private-plan alternative to original Medicare that often combines hospital, medical, and prescription coverage with extra benefits. Understanding its structure, costs, and network rules can help you choose the coverage that best fits your health and budget needs.
