What Is Medicare Advantage? A Deep Dive into How It Works

If you're approaching age 65 or helping a loved one navigate Medicare, you’ve likely heard the term Medicare Advantage (also known as Part C). But what exactly is it, and how does it differ from Original Medicare?

In this post, we’ll break down what Medicare Advantage is, how it works, what it covers, and who should consider it - so you can make informed decisions about your healthcare.

What Is Medicare Advantage?

Medicare Advantage is an all-in-one alternative to Original Medicare (Parts A and B). These plans are offered by private insurance companies approved by Medicare and are required to provide at least the same level of coverage as Original Medicare.

However, most Medicare Advantage plans go beyond that baseline by bundling in additional benefits - often including prescription drug coverage (Part D), dental, vision, hearing, wellness programs, and more.

In other words:
Medicare Advantage = Medicare Parts A + B + often D + extra benefits - all under one plan.

How Medicare Advantage Plans Work

When you enroll in a Medicare Advantage plan, your coverage is managed by a private insurer, not the federal government. Medicare pays the insurance company a fixed amount each month to manage your care.

You still pay your Part B premium (which is $174.70/month in 2025 for most people), and possibly an additional premium to the Advantage plan, although some plans have $0 premiums.

Plan Types

Medicare Advantage comes in different structures, including:

• HMO (Health Maintenance Organization): Requires referrals and restricts you to a provider network.
• PPO (Preferred Provider Organization): Offers more flexibility with out-of-network coverage at a higher cost.
• PFFS (Private Fee-for-Service): Lets you see any provider who agrees to the plan’s terms.
• SNP (Special Needs Plans): Tailored for people with specific chronic conditions, dual eligibility (Medicare + Medicaid), or living in institutions.

What Do Medicare Advantage Plans Cover?

All Medicare Advantage plans must cover everything that Original Medicare covers, including:

• Hospital care (Part A)
• Medical services like doctor visits, labs, and outpatient care (Part B)

But most plans go further. Common extra benefits include:

• Prescription drug coverage (Part D)
• Routine dental care
• Vision services (eye exams, glasses)
• Hearing aids and exams
• Fitness programs (SilverSneakers, etc.)
• Telehealth services
• Transportation to medical appointments
• Over-the-counter (OTC) benefits

However, coverage varies by plan and location, so it’s essential to compare carefully.

Pros and Cons of Medicare Advantage

Pros

• Bundled coverage: Many benefits under one plan
• Low premiums: Some plans have $0 premiums
• Out-of-pocket maximums: Limits how much you pay in a year (unlike Original Medicare)
• Extra benefits: Dental, vision, hearing, fitness, and more
• Coordinated care: Especially in HMOs and SNPs

Cons

• Provider restrictions: Must use network providers in HMOs or pay more in PPOs
• Prior authorizations: May be needed for services or procedures
• Can change yearly: Benefits, premiums, and networks can shift annually
• Limited geographic flexibility: May not be ideal for frequent travelers or snowbirds

Medicare Advantage vs. Medigap

It’s important not to confuse Medicare Advantage with Medigap (also called Medicare Supplement Insurance). You cannot have both at the same time.

• Medicare Advantage replaces Original Medicare and bundles benefits.
• Medigap works with Original Medicare to cover deductibles, coinsurance, and copays.

Key difference: Medigap plans give you more provider flexibility and predictable costs, while Medicare Advantage usually offers extra benefits and lower premiums but with more limitations.

Who Should Consider Medicare Advantage?

Medicare Advantage may be a good fit for people who:

• Want extra benefits like dental and vision
• Prefer all-in-one coverage
• Are comfortable with provider networks
• Want a cap on yearly out-of-pocket costs
• Live in urban areas where plans are more competitive

On the other hand, those with chronic conditions, who travel often, or who want freedom to see any doctor that accepts Medicare, might prefer Original Medicare with a Medigap policy.

Enrollment & Timing

You can enroll in a Medicare Advantage plan during:

• Initial Enrollment Period (IEP): The 7-month window around your 65th birthday
• Annual Enrollment Period (AEP): October 15 to December 7 each year
• Medicare Advantage Open Enrollment: January 1 to March 31 (for plan changes)

Final Thoughts

Medicare Advantage offers convenience, extra benefits, and potential savings - but it’s not one-size-fits-all. It’s vital to weigh the trade-offs between cost, coverage, and flexibility.

Compare plans in your area, consider your medical needs, and don’t hesitate to seek guidance from a licensed Medicare agent.