Medicare Advantage
How Medicare Advantage plans work, what they cover, and the key tradeoffs to understand before you enroll.
What Is Medicare Advantage?
Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies approved by Medicare. Instead of getting your benefits directly from the government, you get them through a private plan.
These plans must cover everything Original Medicare covers (Parts A and B), and most also include Part D drug coverage, dental, vision, and hearing — extras that Original Medicare doesn't cover.
💡 Many Medicare Advantage plans have $0 premiums — but that doesn't mean they're free. You still pay your Part B premium, and you'll have copays and cost-sharing when you use care.
How Medicare Advantage Plans Work
When you enroll in a Medicare Advantage plan, Medicare pays the private insurer a fixed amount each month to provide your coverage. The insurer then manages your benefits and sets the rules for how you access care.
- Network restrictions: Most plans require you to use in-network providers (HMO) or pay more for out-of-network care (PPO).
- Referrals: HMO plans often require a referral from your primary care doctor to see a specialist.
- Prior authorization: Plans can require pre-approval for certain procedures, medications, or specialist visits.
- Out-of-pocket maximum: All MA plans must cap your annual out-of-pocket costs (in 2026, the cap is $9,250 for in-network).
Pros of Medicare Advantage
- Often lower monthly premiums (sometimes $0)
- Includes extras like dental, vision, hearing, and fitness benefits
- Built-in out-of-pocket maximum protects you from catastrophic costs
- Drug coverage (Part D) usually included
- Simple, all-in-one plan
Cons of Medicare Advantage
- Network restrictions — your doctors may not be in-network
- Prior authorization can delay care
- Plans change every year (benefits, networks, costs)
- If you travel frequently or live in multiple states, coverage can be limited
- Harder to switch to a Medigap plan later if you develop health problems
⚠️ The biggest mistake people make: enrolling in Medicare Advantage at 65 and then trying to switch to a Medigap supplement at 70 after a health diagnosis — and getting denied or paying much higher rates due to medical underwriting.
Linda K. enrolled in a $0-premium Advantage plan at 65 — healthy, made sense at the time. At 69 she was diagnosed with a heart condition, and when she tried to switch to a Medigap plan for more freedom with specialists, she was declined by two carriers and quoted nearly double by a third because of medical underwriting. She's still on an Advantage plan today, and manages fine — but the choice she made at 65 turned out to be closer to permanent than anyone told her.
Client stories reflect real situations from Matt's practice. Names and identifying details are changed for privacy.
💡 Before you enroll in any Advantage plan: have someone verify your doctors are in-network and your drugs are on the formulary. Matt does this check for free — most people are shocked by what they find.
Is Medicare Advantage Right for You?
Medicare Advantage can be a great fit if you're relatively healthy, have a preferred network of doctors in-plan, want extra benefits, and want to keep costs simple. It's not ideal if you travel frequently, have complex medical needs, or value the freedom to see any doctor without referrals.
Prefer to watch?
Matt covers everything in this module on video:
Thinking About an Advantage Plan?
Before you enroll in anything, have Matt check your doctors and medications against the actual plans in your zip code. Free, takes minutes, and it can save you from a year stuck in the wrong network.
📞 Call or Text Matt: (248) 895-6656 Have Matt Call You Instead →