Medicare Advantage Plans: What You Need to Know

Medicare Advantage (MA) Plans are offered by private insurance companies that contract with Medicare. Instead of using Original Medicare, enrollees receive all their healthcare benefits through the Advantage Plan.  Each of these plans must offer the same coverage as Original Medicare Part A and B but often provide extra benefits.

What’s Included in Medicare Advantage?

• Hospital coverage (Part A)
• Medical coverage (Part B)
• Prescription drug coverage (most plans)
• Annual out-of-pocket maximum for medical expenses
• May include extra benefits such as: dental, vision, hearing, gym memberships, over-the-counter allowance, and more

Pros & Cons of Medicare Advantage Plans

Medicare Advantage plans aren’t for everyone, but they can be an excellent option depending on individual needs, location, and budget. Below is an objective look at the benefits and potential drawbacks of Medicare Advantage compared to Medicare Supplement (Medigap) plans.

Pros of Medicare Advantage Plans

• Lower monthly premiums: Many plans have a $0 premium or are significantly cheaper than Medigap policies.
• No medical underwriting: Unlike Medigap (Medicare Supplement) Plans, which requires health underwriting outside your initial enrollment period*, anyone eligible for Medicare can enroll in an Advantage Plan.
• Predictable costs: Most plans use set copays for services instead of percentage-based coinsurance.
• Maximum Out-Of-Pocket (MOOP) limit: Medicare Advantage caps your annual medical expenses, unlike Original Medicare, which has no spending limit.
• Extra benefits: Most plans include dental, vision, hearing, fitness programs, and sometimes transportation or Over-The-Counter (OTC) Benefits.
• PPO options for flexibility: Ability to see doctors outside the insurance company’s network at a higher cost, as long as the out of network provider accepts the out of network payment.  This is not guaranteed and should be verified before having any service outside the policy network.
• Network Access: Many insurance companies offer nationwide network access, allowing snowbirds and travelers to pay in-network rates outside their usual area for HMOs, PPOs or HMO-POSs.
• One plan, one card: Medicare Advantage combines hospital, medical, and often drug coverage into a single plan, making it more streamlined than coordinating Medicare, Medigap, and Part D separately.
• Most plans do not require referrals no matter if it is a HMO or PPO.

*Some states have guaranteed issue rules

Cons of Medicare Advantage Plans

• Network restrictions – Most plans require using specific doctors and hospitals, unlike Medigap, which allows access to any Medicare-accepting provider nationwide.  However, some networks have up to 98% of the area providers providing access to a wide range of doctors.
• Referral requirements (HMO Plans) – Some HMOs may require referrals for specialist visits, while PPOs provide more flexibility as long as the out of network provider accepts the out of network payment.
• Out-of-pocket costs for frequent care – While there’s a cap on costs, copays for frequent doctor visits or treatments can add up.
• Plan availability varies by location – Unlike Medigap, which is standardized nationwide, Medicare Advantage plan choices depend on the county you live in and will vary.
• Plan changes every year – Insurance companies can change benefits, networks, and costs annually, requiring an annual review to ensure the plan still meets your needs.

Schedule a Plan Review to Compare Your Options

Who Might Benefit Most from a Medicare Advantage Plan?

• Healthy individuals with few doctor visits – Lower premiums and predictable copays may save money.
• People who want extra benefits – Advantage Plans usually offer dental, vision, hearing, and wellness perks that Original Medicare and Medigap do not.
• Those on a fixed budget – Plans cap out-of-pocket expenses, protecting against unlimited spending like in Original Medicare.
• Individuals who don’t qualify for Medigap* – Those with pre-existing conditions who missed their Medigap Open Enrollment Period may find Medicare Advantage a more accessible option since there’s no underwriting.
• Snowbirds or frequent travelers – Some insurers provide nationwide network access, making Advantage Plans more flexible than in the past.

*Some states have guaranteed issue

Find a Medicare Advantage Plan That Fits Your Needs

Medicare Advantage & Employer Health Insurance

Many people worry that Medicare Advantage plans are too restrictive compared to Original Medicare. However, Advantage Plans typically work in the same way as employer-sponsored health insurance.

• Just like employer plans, Medicare Advantage uses provider networks (HMO, PPO, HMO-POS) and set copays for services rather than unpredictable coinsurance.
• Many people never had an issue using their employer coverage, Medicare Advantage functions similarly, making it a familiar and comfortable option.
• Unlike employer insurance, Medicare Advantage caps out-of-pocket expenses, providing extra financial protection.

For individuals who were comfortable with their employer health plan, transitioning to Medicare Advantage may feel more natural and manageable than they expect.

Common Myths About Medicare Advantage

• “Medicare Advantage is a scam.”
  • Medicare Advantage is a legitimate alternative to Original Medicare, regulated by the federal government. It works well for many individuals, especially those looking for extra benefits or have a tight budget.
• “If I enroll in Medicare Advantage, I can’t switch back.”
  • You can switch between Medicare Advantage and Original Medicare during certain enrollment periods and certain states.
• “Doctors don’t accept Medicare Advantage.”
  • While some doctors don’t accept certain plans, some insurance companies have 98% local provider coverage for both PPO and HMO plans.  Not all doctors and facilities accept Medicare Supplement Plan either.  Never assume.
• “Medicare Advantage doesn’t work for people who travel.”
  • Many Medicare Advantage plans now offer nationwide networks, allowing members to get in-network care outside their home region. Many of our snowbird clients have two sets of doctors in different states and are still charged as in-network.  In addition, Medicare Advantage plans offer emergency and urgent care visits at an in-network cost as well.

Get the Facts: Compare Medicare Options

Choosing the Right Plan for You

Medicare Advantage isn’t the right choice for everyone, but for many, it provides cost-effective, flexible, and comprehensive coverage.

Our team can help you:

• Compare your Medicare options to see if Advantage or Medigap is better for you.
• Check your doctors, hospitals, and prescriptions in network before you enroll.
• Ensure you understand your plan’s benefits and limitations.

Schedule a Free Medicare Consultation