What is Medicare Advantage?
Medicare Advantage (also called Medicare Part C or MA plans) is an alternative way to get your Medicare coverage. Instead of Original Medicare (Parts A & B) provided directly by the federal government, you get all your coverage through a private insurance company approved by Medicare.
These plans must cover everything Original Medicare covers—but most go further, adding prescription drugs, dental, vision, hearing, fitness benefits, and more. Over 50% of Medicare beneficiaries now choose Medicare Advantage over Original Medicare.
What's Included in Most Medicare Advantage Plans
- ✓ Hospital care (Part A)
- ✓ Medical services (Part B)
- ✓ Prescription drugs (Part D) - usually included
- ✓ Dental, vision, and hearing benefits
- ✓ Fitness benefits (gym memberships, fitness classes)
- ✓ Over-the-counter (OTC) allowances
- ✓ Transportation to medical appointments
- ✓ Telehealth services
How Medicare Advantage Works
When you join a Medicare Advantage plan, Medicare pays the private insurance company a set amount each month to provide your coverage. You still have Medicare—the insurance company is just managing your benefits.
You Still Have Medicare
- • You must be enrolled in Parts A & B
- • You still pay Part B premium ($174.70 in 2024)
- • Medicare pays the private company
- • You follow the company's rules (networks, referrals)
- • Can switch back to Original Medicare annually
Private Company Manages Care
- • You use the plan's network of doctors/hospitals
- • May need referrals to see specialists
- • Prior authorization may be required
- • Plan sets copays and deductibles
- • Out-of-pocket maximum protects you
Types of Medicare Advantage Plans
Not all Medicare Advantage plans are the same. The type of plan affects which doctors you can see and whether you need referrals:
Health Maintenance Organization
Most common and usually lowest cost. You choose a primary care physician (PCP) who coordinates your care and provides referrals to see specialists.
You must:
- • Stay in network (except emergencies)
- • Get referrals to see specialists
- • Choose a primary care doctor
Benefits:
- • Lower premiums
- • Coordinated care
- • Predictable costs
Preferred Provider Organization
More flexibility, higher cost. You can see any doctor (in or out of network) without referrals, but you pay less if you stay in-network.
You can:
- • See out-of-network doctors (higher cost)
- • See specialists without referrals
- • Travel and still have coverage
Trade-offs:
- • Higher premiums
- • Higher out-of-pocket costs
- • More complex cost structure
Special Needs Plans
For specific populations. Designed for people with certain chronic conditions (like diabetes or heart failure), those dually eligible for Medicare and Medicaid, or people living in institutions. Benefits are tailored to your specific health needs.
Medicare Advantage Costs
Medicare Advantage plans have different types of costs. Understanding each helps you compare plans and budget for healthcare:
| Cost Type | What It Is | Typical Range |
|---|---|---|
| Monthly Premium | What you pay every month for the plan (in addition to Part B premium) | $0 - $100+ per month |
| Part B Premium | You STILL pay this to Medicare (not the plan) | $174.70/month (2024) |
| Deductible | Amount you pay before plan starts paying | $0 - $500 (many $0) |
| Copays | Fixed amount per visit or service | $0-50 PCP, $30-80 specialist |
| Coinsurance | Percentage you pay for certain services | 15%-20% typical |
| Out-of-Pocket Max | Most you pay in a year (huge protection!) | $3,000 - $8,000+ |
Don't Just Look at the Premium!
A $0 premium plan often has higher copays and coinsurance. If you see doctors frequently, a plan with a higher premium but lower copays may cost less overall. I can help you calculate your total expected costs based on your actual healthcare usage.
Extra Benefits in Medicare Advantage
One of the biggest reasons people choose Medicare Advantage is the extra benefits not covered by Original Medicare. These can save you thousands per year:
Dental, Vision, Hearing
Most plans include benefits Original Medicare doesn't cover:
- • Routine dental cleanings, fillings, extractions
- • Eye exams and eyeglasses/contacts allowance
- • Hearing exams and hearing aid allowances
Fitness & Wellness
Stay active with fitness benefits:
- • Gym memberships (often SilverSneakers or Renew Active)
- • Fitness classes and activities
- • Home fitness equipment
- • Wellness programs and coaching
Over-the-Counter (OTC)
Quarterly allowances for health items:
- • Cold & flu medicine, pain relievers
- • Vitamins and supplements
- • First aid supplies, thermometers
- • Dental care, skin care products
Transportation
Get to your medical appointments:
- • Rides to doctor appointments
- • Trips to pharmacy
- • Transportation to get prescriptions
- • Some include non-medical trips
Pros & Cons of Medicare Advantage
Medicare Advantage isn't right for everyone. Here's an honest look at the advantages and limitations:
Advantages
- ✓ Extra benefits - dental, vision, hearing, fitness
- ✓ Out-of-pocket maximum - protection from catastrophic costs
- ✓ All-in-one - hospital, medical, and usually drug coverage
- ✓ Lower premiums - many $0 premium plans available
- ✓ Coordinated care - one company managing everything
- ✓ Innovative benefits - telehealth, wellness programs
Limitations
- ⚠ Network restrictions - must use plan's doctors (except emergencies)
- ⚠ Referrals often required - especially in HMO plans
- ⚠ Prior authorization - plan must approve certain services
- ⚠ Service area limits - limited coverage when traveling
- ⚠ Copays add up - each visit/service has a cost
- ⚠ Annual changes - plans can change networks, costs, benefits yearly
Who Benefits Most from Medicare Advantage?
Medicare Advantage works great for certain people. Consider it if you:
- Want extra benefits like dental, vision, and hearing coverage
- Prefer predictable copays over unexpected bills
- Are comfortable using a network of doctors
- Don't travel frequently or live in multiple states
- Want an out-of-pocket maximum for financial protection
- Value fitness benefits and wellness programs
- Want prescription drug coverage included in your plan
Medicare Advantage may NOT be the best choice if you:
- Want complete freedom to see any doctor nationwide without referrals
- Have complex health conditions requiring multiple specialists
- Travel frequently or spend winters in another state
- Prefer lower out-of-pocket costs when you use care (even with higher premiums)
- Want coverage that doesn't change year-to-year
Enrolling in Medicare Advantage
You can enroll in Medicare Advantage during specific periods:
Initial Enrollment Period (IEP)
When you first become eligible for Medicare (around age 65), you have 7 months to join a Medicare Advantage plan.
Annual Enrollment Period (AEP)
October 15 - December 7 every year. Switch plans, change carriers, or move between Medicare Advantage and Original Medicare. Changes effective January 1.
Medicare Advantage Open Enrollment
January 1 - March 31 if you're already in a Medicare Advantage plan. Switch to a different MA plan or drop MA and return to Original Medicare (one time only).
Get Expert Medicare Advantage Help
With dozens of Medicare Advantage plans available in Texas, comparing options can be overwhelming. I can help you:
- Compare all Medicare Advantage plans in your area
- Check if your doctors are in-network
- Verify your prescriptions are covered at low cost
- Calculate your total annual costs (not just premiums)
- Understand the trade-offs between plans
- Enroll in your chosen plan
Compare Medicare Advantage Plans
Let's review your doctors, medications, and healthcare needs to find the Medicare Advantage plan that's right for you. Free consultation, no pressure.