Medicare education
How Medicare Advantage actually works
Medicare Advantage plans are heavily advertised, and the ads tend to lead with the extras. Here's the fuller picture: how these plans are structured, what the tradeoffs are, and how to judge whether one fits your situation.
The basics
Medicare Advantage, also called Part C, is a way to receive your Medicare benefits through a private insurance company instead of directly through the federal program. The plan must cover everything Original Medicare covers, and most plans bundle in prescription drug coverage and extras like dental, vision, or hearing allowances.
In exchange, these plans typically manage how you use care. That usually means a provider network, copays or coinsurance when you receive services, and sometimes prior authorization for certain procedures.
The tradeoffs, honestly
What people tend to like
- Lower monthly premiums, sometimes very low
- Drug coverage built into one plan
- Extra benefits Original Medicare doesn't include
- A yearly cap on out-of-pocket medical costs
What deserves a closer look
- Networks limit which doctors and hospitals you can use
- You pay copays and coinsurance as you use care
- Some services need plan approval first
- Benefits, networks, and drug lists can change every year
None of this makes Medicare Advantage good or bad. It makes it a fit for some situations and not others. Someone who's comfortable with a network and wants a low premium may do well here. Someone who travels often or wants maximum doctor flexibility may want to compare it carefully against a Medicare Supplement.
Common questions
Can I keep my doctor on a Medicare Advantage plan?
It depends on the plan's network. Every Medicare Advantage plan has its own list of contracted doctors and hospitals, and those lists change. Before anyone enrolls, we check that their doctors and preferred hospital are in the network of any plan they're considering.
Why do some Medicare Advantage plans have low or no monthly premium?
Medicare pays private insurance companies a set amount to manage your care, which is how plans can charge low premiums. The tradeoff is usually cost-sharing when you use services, like copays for visits and hospital stays, and a yearly out-of-pocket maximum that caps your exposure.
What happens if my plan changes next year?
Plans can change their networks, drug lists, and benefits every calendar year. You get an Annual Notice of Change each fall, and the Annual Enrollment Period from October 15 to December 7 is your chance to review and switch. We help our clients review those notices every year.
Do Medicare Advantage plans include drug coverage?
Most include prescription drug coverage, but not all. And the drug list, called a formulary, differs from plan to plan. Checking your specific prescriptions against a plan's formulary is one of the most important steps before enrolling.
Wondering if Medicare Advantage fits your situation?
We'll check your doctors, your prescriptions, and your budget against what's actually available in your county. Then you decide.