What Is Medicare Advantage and Who Qualifies?

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Medicare Advantage is an alternative to Original Medicare that is administered by private insurers and often includes all of the parts of Medicare plus additional coverage types like vision and dental insurance. Eligible Medicare members can qualify for a Medicare Advantage plan if they live in that plan’s service area and they will usually only have to pay the premium for Medicare Part B.

Read below to learn more about what Medicare Advantage is along with the benefits and drawbacks you should consider when deciding whether you want to switch from Original Medicare to Medicare Advantage.

Key Takeaways

  • Medicare Advantage plans are sold to eligible Medicare members by private health insurance companies that are reimbursed by the federal government.
  • Also known as Medicare Part C, a typical Medicare Advantage plan will include Medicare Parts A, B and D and may come with extra coverage types like vision, hearing and dental insurance.
  • You can qualify for Medicare Advantage if you are already on Original Medicare, live in your preferred plan’s service area and are either a citizen or lawful resident of the United States.
  • Most Medicare Advantage plans don’t cost anything besides the Part B premium you pay to Medicare, although the average cost for plans that do have an additional premium is $57 per month.
  • Medicare Part C plans generally have smaller networks than Original Medicare and may place more restrictions on when certain supplies or services are covered.

What Is Medicare Advantage and How Does It Work?

Also known as Medicare Part C, Medicare Advantage is an alternative to Original Medicare that is provided by private insurance companies rather than the federal government. Medicare Advantage companies are required to follow rules set by the Centers for Medicare & Medicaid Services. Participating insurers receive reimbursement from the federal government at a fixed rate every month in exchange for covering Medicare members.[1]

What Are the Benefits of a Medicare Advantage Plan?

A typical Medicare Advantage plan comes with all of the other parts of Medicare, which means your plan should help pay for inpatient hospital care (Part A), outpatient medical services (Part B) and prescription drugs (Part D). In addition, Part C plans often provide extra coverage that isn’t included in Original Medicare such as gym membership, vision, hearing and dental insurance.

Another benefit of Medicare Advantage is that it usually comes with an annual limit on the amount of money you have to pay out of pocket through deductibles, copays and coinsurance. Once you reach that limit, your insurance carrier will cover 100% of the costs for covered medical services for the rest of the year. Conversely, Original Medicare has no out-of-pocket maximum, meaning you will always pay a share of the costs for covered medical services unless you buy Medicare Supplement insurance.[1]

Although they generally offer more coverage than Original Medicare plans, Medicare Advantage plans often don’t have a separate premium.

Instead, most plans only require you to pay the premium for Medicare Part B.[2] Some Part C plans may even lower your costs by covering all or part of your Part B premium.[1]

Are There Any Disadvantages?

The primary drawback of Medicare Advantage compared to Original Medicare is its lack of flexibility. With a Medicare Part C plan, you may need a referral from your primary care physician to see a specialist and your plan may only cover certain supplies and services if you get them approved in advance, which isn’t the case with Original Medicare.[1]

Similarly, your Medicare Advantage company may only cover non-emergency care from in-network providers or may require you to pay a greater portion of the costs for out-of-network care. Conversely, Original Medicare covers care from every medical provider in the United States that accepts Medicare.[1]

Meanwhile, Medicare Part C may exclude coverage for a handful of medical services like clinical trials and hospice care, although you may still be able to receive coverage for these services through Original Medicare even if you stay on your Medicare Advantage plan. In addition, Medicare Advantage may not immediately cover benefits that have been recently established by law or national coverage determinations.[1]

If you already have health insurance through an employer or union, joining a Medicare Advantage plan could cause you to lose that coverage for yourself, your spouse and your dependents. As a result, you should talk to your benefits administrator to see whether you would lose your existing coverage and whether it would be worth trading in these benefits for a certain Medicare Part C plan.[1]

What Types of Medicare Advantage Plans Are There?

See the below table for an overview of the main types of plans offered by Medicare Advantage companies. Keep in mind that not every type of plan will necessarily be available in your area.[1]

Plan Type


HMO (Health Maintenance Organization)

HMO plans exclusively cover in-network care except in emergencies and require you to get a referral before you can see a specialist

PPO (Preferred Provider Organization)

PPO plans don’t require you to get a referral to see a specialist and they cover both in-network and out-of-network care, although you will have to pay more for out-of-network care

PFFS (Private Fee-for-Service)

PFFS plans do not necessarily have a specific network but instead cover treatments from any medical provider that accepts Medicare, approves of the terms of your plan and agrees to treat you

SNPs (Special Needs Plans)

SNPs can be HMO, PPO or HMO-POS (point of service) plans that include extra coverage to meet the needs of people who have chronic conditions, require institutional care or are eligible for both Medicare and Medicaid

Medical Savings Account (MSA)

MSA plans have high deductibles and include savings accounts with money deposited by Medicare, which you can use to pay for medical services before hitting your deductible even if those services would not otherwise be covered by Medicare

Who Is Eligible for Medicare Advantage?

To qualify for Medicare Advantage, you must first meet the basic eligibility requirements for Original Medicare. This means you must be at least 65 years old or you must have a disability, end-stage renal disease or Lou Gehrig’s disease.[3]

If you are eligible for Medicare and have enrolled in Parts A and B, then you can sign up for a Medicare Advantage plan as long as you live in that plan’s service area and are a citizen or lawful resident of the United States.[1]

Which Insurance Companies Offer Medicare Advantage?

You can buy Medicare Advantage plans through major health insurance companies such as the following:

  • Aetna
  • Blue Cross Blue Shield
  • CareSource
  • Cigna
  • HCSC
  • Humana
  • Kaiser Permanente
  • Molina
  • Oscar
  • UnitedHealthcare
  • Wellcare

How Do I Choose the Best Medicare Advantage Plan?

Cost, coverage and quality are the primary factors you’ll want to consider as you look for the right Medicare Advantage plan. While most plans only require you to pay for Medicare Part B, the average cost of plans that do come with an additional Part C premium is $57 per month.[2]

Before purchasing a plan, pay attention to whether it automatically comes with prescription drug coverage or any other coverage types you are interested in and can afford. If not, consider whether you would be better off sticking to Original Medicare.

Since Medicare Advantage plans often have limited networks, you should check whether any doctors you currently see are in a plan’s network before committing to that plan. You can also inform your decision by looking up a plan’s Medicare star rating, which is a measure of its overall quality based on upwards of 40 factors.[4]

How To Enroll in a Medicare Advantage Plan

Before picking a Medicare Advantage plan, it’s helpful to compare quotes from at least three to five insurance providers. You can do so by browsing Medicare.gov or calling 1-800-MEDICARE (1-800-633-4227).[1] Alternatively, you can type your zip code below to compare Medicare quotes through SmartFinancial’s online health insurance marketplace.

Once you have settled on a Medicare Advantage plan that matches your coverage needs and budget, you should be able to enroll in it by providing information like the Medicare Number listed on your Medicare card and the date you enrolled in Medicare Parts A and B.[1]

You can join a Medicare Advantage plan during your Medicare initial enrollment period, which is a seven-month window beginning three months before the month you turn 65. Afterward, you can adjust your coverage during Medicare open enrollment from October 15 to December 7 or Medicare Advantage open enrollment from January 1 to March 31. Otherwise, you can only change plans if a qualifying life event triggers a special enrollment period.[1]

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Can you sign up for Medicare Advantage with preexisting conditions?

Yes, you can sign up for Medicare Advantage if you have a preexisting condition.[1]

Who can enroll in a Medicare Advantage plan?

You can enroll in a Medicare Advantage plan if you already have Medicare Parts A and B, live in your selected plan’s service area and are either an American citizen or lawful resident.[1]

What’s the difference between Medicare and Medicare Advantage?

Medicare is a government-funded health insurance program for elderly and disabled people, while Medicare Advantage is a private alternative that often includes all of the parts of Medicare plus other coverage types like vision and dental insurance.

What’s the difference between Medigap and Medicare Advantage?

Also known as Medicare Supplement insurance, Medigap complements Original Medicare by paying some of your out-of-pocket costs, while Medicare Advantage replaces Original Medicare by providing the same and sometimes additional coverage. You generally cannot have both Medigap and Medicare Advantage.[1]


  1. Centers for Medicare & Medicaid Services. “Understanding Medicare Advantage Plans,” Pages 6-7, 9, 12-15, 17 and 27. Accessed Oct. 17, 2023.
  2. KFF. “Medicare Advantage in 2023: Premiums, Out-of-Pocket Limits, Cost Sharing, Supplemental Benefits, Prior Authorization, and Star Ratings.” Accessed Oct. 17, 2023.
  3. United States Department of Health and Human Services. “Who’s Eligible for Medicare?” Accessed Oct. 17, 2023.
  4. Centers for Medicare & Medicaid Services. “Fact Sheet - 2024 Medicare Advantage and Part D Star Ratings,” Page 1. Accessed Oct. 17, 2023.

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