Today, over one-third of all Medicare beneficiaries are in Medicare Advantage plans, according to the Centers for Medicare and Medicaid Services (CMS). Depending on where you live, you may have several options for health insurance providers of Medicare Advantage plans. Although Medicare Advantage plans are highly regulated by the government, they may vary in some ways.

How do costs differ for providers of Medicare Advantage plans?

One essential difference between Original Medicare and Medicare Advantage is that Medicare Advantage plans are offered by private insurance companies approved by Medicare. This means they are free to set their own premiums and cost structures.

Premiums can vary widely from company to company and plan to plan. In fact, you may be able to find a zero-premium plan in your area. Keep in mind, however, that you will always have to pay your Medicare Part B premium, plus any other premium required by your plan, as long as you are enrolled in Medicare Advantage.

Medicare Advantage plans may or may not have an annual deductible before full benefits kick in. A deductible is an amount you pay out-of-pocket. There may also be differences in terms of cost-sharing. Some plans use a copayment system, in which you pay a flat fee each time you receive medical care. The copayment may be lower for primary care and higher for specialist care. Other plans charge a percentage of the actual cost of your care called coinsurance.

All Medicare Advantage plans have a maximum out-of-pocket limit, after which your medical expenses are covered at 100%. This may vary from plan to plan, but may never exceed the limit set each year by Medicare.

How do benefits differ for providers of Medicare Advantage plans?

Most Medicare Advantage plans include Part D coverage for prescription drugs, although some do not. You may also get discounts or an allowance toward over-the-counter medications with some Medicare Advantage plans.

All Medicare Advantage plans must cover, at a minimum, everything covered by Original Medicare, except for hospice care, which is still covered by Part A. From there, they may choose to offer additional benefits, such as coverage for

  • routine vision
  • dental
  • hearing care
  • Some may also cover the Silver Sneakers program, which is a fitness and gym membership program.

Are there any other differences between providers of Medicare Advantage plans?

There are several types of Medicare Advantage plans, but the most common are managed care plans, either health maintenance organizations (HMOs) and preferred provider organizations (PPOs*). These plans use provider networks to help keep costs low for their members. With an HMO, you are required to get all your non-emergency health care from providers within the plan’s network. With a PPO, you can choose any provider you like, but you pay less out of pocket if you use network providers.

If you have a relationship with a particular doctor, hospital, or pharmacy and would like to maintain it once you switch to Medicare Advantage, it’s a good idea to check with the plans you are interested in to see whether your favorite providers are included in the plan’s network.

Would you like more information about Medicare Advantage plans?

I am happy to help you find the information you need; to get started, simply click the Get Quotes button to schedule a phone call or to request a personalized email.

Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.
The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.