What Retirees Actually Want to Know About Medicare Advantage

The eight questions retirees ask most about Medicare Advantage

Medicare Advantage is a way to get your Medicare coverage through a private insurance company instead of through Original Medicare. The company must cover everything Original Medicare covers, but the way they do it — the doctors you can see, the costs you pay, the extra benefits included — varies widely by plan and by where you live. Most retirees' real questions are not about what Medicare Advantage is, but whether it makes sense for them, what happens if they change their mind, and whether they can actually afford it.

The eight questions below are the ones that come up repeatedly when retirees are trying to decide. The answers depend on your health, your budget, which plans are available where you live, and what you value most — and those things change. This guide walks through what each question really means and where to find the answer that fits your situation.

Key Takeaways

• Medicare Advantage plans vary by county and change every year, so the plan available to you in one state or one year may not be available the next.
• You can switch to a different Medicare Advantage plan or back to Original Medicare during the annual enrollment period (October 15 to December 7), or if you move or lose your current coverage.
• Medicare Advantage plans include prescription drug coverage, but Original Medicare does not — so the total cost comparison is not straightforward.
• Your out-of-pocket costs depend on which doctors and hospitals you actually use, because in-network care costs less than out-of-network care in most plans.
• If you have a chronic condition or take many medications, ask the plan directly whether your doctors and drugs are covered before you enroll.

What is the difference between Medicare Advantage and Original Medicare?

Original Medicare is run by the federal government and covers hospital care (Part A) and doctor visits (Part B). You can see any doctor or hospital that accepts Medicare, anywhere in the country. You pay a deductible and coinsurance, and you have to buy a separate prescription drug plan (Part D) if you want drug coverage.

Medicare Advantage is sold by private insurance companies and must cover everything Original Medicare covers, but the company decides how. Most Medicare Advantage plans use a network — you pay less if you see doctors and hospitals in the network, and more (or nothing is covered) if you go out of network. Most plans include prescription drug coverage built in, so you do not buy a separate Part D plan. Many plans also include dental, vision, or hearing coverage that Original Medicare does not offer.

The trade-off is that with Medicare Advantage you are locked into a network and a specific insurance company's rules, but you usually pay lower monthly premiums and you get extra benefits. With Original Medicare you have more freedom to see any provider, but you pay more out of pocket and you have to manage multiple plans.

How do I know if a Medicare Advantage plan covers my doctor or my medications?

Every Medicare Advantage plan publishes a formulary (the list of drugs it covers) and a provider directory (the list of doctors and hospitals in its network). Both are available on the plan's website, and you should check both before you enroll — not after. Search for your primary care doctor, any specialists you see regularly, your pharmacy, and each medication you take by name and dose.

If your doctor or drug is not listed, call the plan directly and ask whether it is covered. Sometimes the directory is out of date, or a drug is covered under a different name, or it is covered but requires prior approval from the plan before your doctor can prescribe it. Do not assume the answer is no until you have asked.

If your current doctor is not in the network and you want to keep seeing them, you have two choices: pick a different plan that includes them, or stay on Original Medicare. If your current medication is not covered, the plan may cover a similar drug, or it may require you to try a cheaper drug first before it will cover the one your doctor wants — this is called a step therapy requirement.

What happens if I enroll in Medicare Advantage and then change my mind?

You can switch plans or go back to Original Medicare, but only during specific windows. The main window is the annual enrollment period, which runs from October 15 to December 7 each year. Any change you make during this period takes effect on January 1. You can also switch if you move to a new state or county, if you lose your current coverage, or if you are newly may be able to access for Medicare.

There is one important exception: if you have been on Medicare Advantage for less than one year and you want to switch back to Original Medicare, you can do so during the first three months you are enrolled. After that, you are locked in until the next annual enrollment period. This is called the Medicare Advantage disenrollment period, and it is your only chance to leave without waiting a full year.

If you switch back to Original Medicare, you will need to buy a Medigap plan (supplemental insurance) or a Part D plan (prescription drugs) separately, and insurance companies can deny you or charge you more based on your health. If you stay on Medicare Advantage, you cannot buy a Medigap plan at all — the two are not compatible.

How much will I actually pay out of pocket?

Your out-of-pocket costs depend on which doctors and hospitals you use and whether they are in the plan's network. Every plan has a monthly premium (what you pay to the insurance company), a deductible (what you pay before the plan starts paying), copays (a flat fee per visit), and coinsurance (a percentage of the cost). The plan also has an out-of-pocket maximum — once you hit that number in a year, the plan pays everything else.

The problem is that you cannot know your total cost until you know which doctors you will see and how often. If you see your primary care doctor once a year and take one medication, your costs will be very different from someone who sees three specialists and takes five medications. Use the plan's online cost calculator if it has one, or call the plan and walk through your specific doctors and drugs.

Also check whether the plan covers care outside the network. Some plans cover out-of-network emergency care but nothing else. Others cover some out-of-network care at a higher cost. If you travel frequently or see a specialist who is not in the network, this matters.

Do Medicare Advantage plans cover prescription drugs?

Yes — every Medicare Advantage plan must include prescription drug coverage. You do not buy a separate Part D plan. The plan's formulary tells you which drugs are covered and what you pay for each one. Some drugs are free, some have a copay, and some have coinsurance (you pay a percentage of the cost).

The plan may also require prior authorization — the plan has to approve the drug before your doctor can prescribe it — or step therapy, which means you have to try a cheaper drug first. If your doctor prescribes a drug that is not on the formulary, the plan will not cover it, and you will have to pay the full price yourself or ask your doctor to prescribe something else.

Drug coverage changes every year, so a drug that was covered last year may not be covered this year, or it may move to a higher cost tier. Check the formulary every October when plans change, especially if you take a medication that is expensive or hard to replace.

What if I have a chronic condition like diabetes or heart disease?

If you have a chronic condition, you need to know whether the plan covers the specific doctors and treatments you need. Call the plan and ask whether your cardiologist, endocrinologist, or other specialist is in the network. Ask whether the plan covers the tests, medications, and procedures your condition requires. Some plans have disease management programs for chronic conditions — they may offer free supplies, nurse hotlines, or care coordination that can help.

Also ask about the plan's prior authorization requirements. Some plans require approval before you can see a specialist or get certain tests or procedures. This can slow down your care, so it is worth knowing in advance.

If your current doctor is not in the network and you cannot find another one you trust, Original Medicare may be a better fit, even though the monthly cost is higher. The cost of switching doctors or delaying treatment is often higher than the cost of a higher premium.

Can I use my Medicare Advantage plan if I travel or move?

Medicare Advantage plans are tied to a specific county or region. If you travel within the United States, your plan covers emergency care anywhere, but routine care is only covered in-network. If you travel frequently or for long periods, ask the plan whether it has a national network or partnerships with other plans in the places you visit.

If you move to a different county or state, your current plan may not be available there. You will have a special enrollment period to switch to a different plan or to Original Medicare. Start looking for a new plan as soon as you know you are moving, because the plans available in your new location may be very different from the ones you have now.

If you spend part of the year in one state and part in another (called being a snowbird), you may be able to stay on your current plan if both locations are in the same service area, but you should confirm this with the plan before you move.

What extra benefits do Medicare Advantage plans offer?

Many Medicare Advantage plans include benefits that Original Medicare does not: dental (cleanings, fillings, sometimes dentures), vision (eye exams, glasses, contacts), hearing (exams and hearing aids), fitness programs (gym memberships or exercise classes), and transportation to medical appointments. Some plans also cover over-the-counter items like pain relievers or vitamins, or they offer meal delivery or home safety modifications.

These benefits sound appealing, but they come with limits. Dental coverage often has an annual maximum (the plan will only pay up to $1,000 or $1,500 per year), and it may not cover major work like root canals or implants. Vision coverage may only pay for one eye exam per year and one pair of glasses. Hearing aid coverage may only cover one hearing aid per ear every few years. Read the plan's summary of benefits to see the actual limits before you enroll.

Also remember that these benefits are only available if you use in-network providers. If your dentist or eye doctor is not in the plan's network, you will have to pay out of pocket or find a different provider.

How do I compare Medicare Advantage plans in my area?

Medicare publishes a plan comparison tool on Medicare.gov where you can enter your location, your doctors, and your medications, and it will show you which plans cover them and what your costs would be. You can also call 1-800-MEDICARE to speak with someone who can walk you through the options.

When you compare plans, look at the monthly premium, the deductible, the copays and coinsurance, the out-of-pocket maximum, and whether your doctors and drugs are covered. Do not just pick the plan with the lowest premium — the plan with the lowest premium may have higher copays or a smaller network. Use a spreadsheet or a piece of paper to write down the costs for each plan based on your specific situation, then add them up to see which plan costs the least overall.

Also check whether the plan is rated well by current members. Medicare publishes star ratings for each plan based on member surveys and quality measures. A plan with four or five stars usually means members are satisfied with the coverage and customer service.

Frequently Asked Questions

Can I switch from one Medicare Advantage plan to another during the year?

No, not unless you have a may have access to event like moving, losing coverage, or becoming newly may be able to access for Medicare. The only time you can switch plans is during the annual enrollment period (October 15 to December 7). If you enroll in a plan and realize it is not right for you, you are stuck with it until the next enrollment period — unless you are in your first three months on Medicare Advantage, in which case you can switch back to Original Medicare.

What if my Medicare Advantage plan gets discontinued?

If your plan is discontinued, Medicare will send you a notice and give you a special enrollment period to switch to a different plan. You will have time to review your options and pick a new plan before your current one ends. If you do not pick a new plan, Medicare will automatically enroll you in a different plan in your area, but you should choose your own plan rather than letting this happen.

Do I still have to pay my Part B premium if I am on Medicare Advantage?

Yes. You pay your Part B premium to Medicare, and you pay the Medicare Advantage plan's premium to the insurance company. Some Medicare Advantage plans have a $0 premium, meaning you only pay the Part B premium, but many plans charge an additional monthly premium on top of Part B.

What happens to my Medicare Advantage coverage if I move to a nursing home or assisted living?

Your Medicare Advantage plan continues to cover you, but you should tell the plan that you have moved. Some plans have special rules for people in institutional settings, and the plan needs to know where you are to coordinate your care. If your new location is outside the plan's service area, you will have a special enrollment period to switch to a plan that covers your new location.

Can I have both Medicare Advantage and Medigap at the same time?

No. Medicare does not allow you to have both. If you are on Medicare Advantage and you want to buy a Medigap plan, you have to switch back to Original Medicare first. If you are on Original Medicare with a Medigap plan and you want to switch to Medicare Advantage, you have to drop the Medigap plan — you cannot keep both.